Consultant Pharmacist Failed to Identify Medication Order Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and addressed medication regimen irregularities for two residents. For one resident with multiple complex diagnoses, including severe protein-calorie malnutrition, chronic kidney disease, major depressive disorder, and paraplegia, the CP did not identify that a PRN (as-needed) lorazepam order lacked a required stop or discontinue date. The resident's care plan noted high-risk medication use, and the physician's order allowed lorazepam administration every four hours as needed, but without a stop date. The CP's monthly review did not document any recommendations regarding this omission. Facility staff confirmed that the PRN lorazepam order was indefinite and acknowledged that the CP should have identified the missing stop date, as per facility policy. Additionally, the report notes that the facility's Drug Regimen Review Report Distribution policy requires the CP to report any recommendations of apparent irregularities resulting from the medication regimen review to the attending physician and/or the director of nursing, and that each recommendation must be acted upon. However, the CP failed to identify and report the irregularity in the medication order, and there was no documentation of recommendations or follow-up. This failure was observed through record review, staff interviews, and direct observation of the resident.