Pharmacist Failed to Identify Missing Dose in Medication Order
Penalty
Summary
A deficiency occurred when a licensed pharmacist failed to identify and report a medication irregularity for one resident during the required monthly drug regimen review. The resident had a physician's order for docusate sodium, but the order did not specify the dose to be administered. Despite this omission, the medication was administered as one 100 mg tablet twice daily via gastrostomy tube (GT), based on the facility's available stock, without clarification from the physician. The medication administration record (MAR) and the physician's order both lacked the specified dose, and the resident had been receiving the medication in this manner since the order was written. During interviews, the LVN confirmed that the dose was assumed due to the available tablet strength and acknowledged that clarification should have been sought. The consultant pharmacist, upon review, stated that each medication order should include a specified dose and acknowledged that the missing dose was not identified during the monthly medication regimen review. The facility's policy required the pharmacist to identify such irregularities, but this was not done, resulting in the deficiency.