Consulting Pharmacist Failed to Identify Medication Administration Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified and reported instances where a resident received midodrine outside of the physician-ordered parameters. The resident had multiple diagnoses, including cognitive communication deficit, hypotension, edema, muscle weakness, and required assistance with personal care. Physician orders specified that midodrine should not be administered if the resident's systolic blood pressure (SBP) exceeded 140 mmHg. However, review of the Medication Administration Record and Treatment Administration Record over a 45-day period showed that midodrine was administered eight times when the resident's SBP was above the ordered threshold. Further review of the Monthly Medication Reviews from September 2024 to May 2025 revealed no evidence that the consulting pharmacist identified or reported these deviations from the physician's order. Interviews with facility staff confirmed the expectation that the pharmacist should have recognized and reported the medication administration outside of the prescribed parameters. Additionally, the facility was unable to provide a policy outlining the pharmacy's responsibility for monthly medication reviews.