Consulting Pharmacist Failed to Identify and Report Medication Parameter Irregularities
Penalty
Summary
The consulting pharmacist failed to identify and report irregularities related to physician-ordered medication parameters for two residents during monthly drug regimen reviews. For one resident with moderate cognitive impairment and diagnoses including gastroparesis, malnutrition, and fecal impaction, physician orders required metoprolol to be held if systolic blood pressure was less than 100. However, the medication administration record showed the medication was given without documentation of blood pressure checks, and the order on the MAR did not include the hold parameter. Over the previous six months, pharmacy reviews did not identify that the blood pressure parameter was not being followed. For another resident with neuromyelitis optica and diabetes, physician orders required hydralazine and carvedilol to be held if mean arterial pressure (MAP) was less than 65. The MAR showed hydralazine was administered with blood pressure recorded instead of MAP, and carvedilol was given without any vital signs documented. The consulting pharmacist did not identify that MAP parameters were not being followed or recommend reviewing the appropriateness of using MAP as a parameter in this setting. Interviews with facility staff and the medical director confirmed that MAP is not a standard parameter in nursing homes and that the pharmacist failed to recognize and report these discrepancies during monthly reviews.