Failure to Identify and Report Medication Monitoring Irregularities
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified and reported irregularities related to the long-term use of anti-psychotic and thyroid medications for one resident. The resident had been receiving Levothyroxine Sodium for hypothyroidism and Abilify for bipolar disorder over an extended period. Review of the medical record showed there were no current physician's orders for laboratory testing to monitor thyroid function (TSH or free T4) or fasting blood glucose, despite the known need for such monitoring with these medications. The last available laboratory data was from a hospital visit, not from routine facility-ordered monitoring, and showed abnormal glucose levels. Over the past year, monthly medication regimen reviews by the consultant pharmacist did not include any recommendations for necessary laboratory assessments related to the use of Levothyroxine Sodium or Abilify. Interviews with the DON and the consultant pharmacist confirmed the absence of such monitoring and recommendations. The facility's policy requires comprehensive monthly medication reviews, including evaluation of medication response and reporting of findings, but this was not followed in this case.