Failure to Identify and Report Duplicate Opioid Orders During Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities during the monthly medication regimen review for one resident. Specifically, the resident was admitted with a diagnosis of type 2 diabetes mellitus and had two similar physician orders for Dilaudid (hydromorphone), both prescribed at the same dose and frequency, as well as an order for a Fentanyl patch. The orders included Dilaudid 2 mg, 4 tablets by mouth every 3 hours as needed for pain, and hydromorphone 8 mg, 1 tablet by mouth every 3 hours as needed for pain, with a maximum of 4 tablets per day. The duplicate orders were not identified or reported as irregularities in the medication regimen review conducted by the CP. Interviews and record reviews confirmed that the duplicate orders existed and were not addressed in the MRR. The CP acknowledged during an interview that the duplicate order was missed and should have been recommended for discontinuation. Additionally, a review of the controlled drug records showed that the resident received hydromorphone 8 mg five times in one day, exceeding the maximum ordered dose. The facility's policy required a thorough evaluation of the medication regimen to prevent, identify, report, and resolve medication-related problems, which was not followed in this instance.