Failure to Prevent Duplicate Medication Orders and Ensure Accurate Pharmaceutical Review
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided in accordance with established procedures to guarantee accurate order entry, dispensing, and administration of medications for a resident with osteoporosis. Specifically, a duplicate order for Alendronate 70mg was entered, resulting in the resident receiving the medication twice weekly instead of once, as intended. Medication Administration Records confirmed that both doses were administered on consecutive Sundays and Mondays. This duplication error was not identified or addressed by the facility's medication management system or during the monthly consultant pharmacist review. Additionally, the resident had an active order for Enoxaparin, an injectable blood thinner, with no documented stop date or clarification of the treatment course. The consultant pharmacist's review did not address the duplicate Alendronate order or clarify the ongoing use of Enoxaparin, despite reviewing the resident's regimen monthly. Interviews with facility staff and the consultant pharmacist revealed an overreliance on the system to flag duplications and a lack of proactive review to identify and resolve medication order issues.