Consultant Pharmacist Failed to Identify Missing Seroquel Monitoring
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for a resident who was prescribed Seroquel, an antipsychotic medication. The resident, who had a diagnosis of schizoaffective disorder, had been receiving Seroquel in various doses since February 2022. Despite manufacturer guidelines requiring monitoring of lipids, TSH, and Free T4 during Seroquel use, there was no documentation of these tests in the resident's medical record. The CP's monthly MRRs from January through April 2025 did not include any recommendations or notations regarding the absence of this required monitoring. Interviews with the QA nurse and the DON confirmed that the required monitoring was not documented and that the CP should have identified and reported this irregularity. The CP also acknowledged during an interview that the monitoring should have been performed and reported when missing. The facility's policy on psychotropic medication use required ongoing evaluation and monitoring in accordance with clinical standards and manufacturer specifications, which was not followed in this case.