Consultant Pharmacist Failed to Report Missed Neurology Consult and Medication Discrepancy
Penalty
Summary
The Consultant Pharmacist failed to report to the attending physician when a resident's record showed that a recommended neurology consult was never obtained after the resident experienced a newly diagnosed neurological disorder and was started on Keppra during a hospital stay. The hospital discharge summary specifically instructed that neurology should be involved in the continued plan for Keppra, and an appointment was requested for follow-up. Upon admission to the facility, Keppra was ordered, but no neurology consultation was initiated or ordered. The Consultant Pharmacist noted the need to 'follow for neuro' in monthly reviews but did not address the absence of the neurology consult or report this irregularity to the physician as required by facility policy and procedures. Additionally, Keppra was discontinued by verbal order with no documented reason, and the neurology consult still had not been completed at the time of discontinuation. The physician later documented Keppra as an active medication in a progress note, despite having signed the discontinuation order. The Consultant Pharmacist did not seek clarification from the physician regarding this discrepancy or the lack of neurology follow-up. Interviews with the Consultant Pharmacist and the Pharmacy Director of Clinical Services confirmed that the pharmacist did not question the rationale for discontinuation or the absence of the neurology consult, failing to follow irregularity reporting guidelines.