Failure to Identify and Report Irregularities in Antihypertensive Medication Monitoring
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities related to the monitoring of antihypertensive medication for a resident. The resident had diagnoses including adult failure to thrive, cognitive communication deficit, congestive heart failure, and hypertension, and required substantial to maximum assistance with activities of daily living. The resident was prescribed Toprol XL, an antihypertensive medication, but a review of the Medication Administration Record (MAR), Treatment Administration Record (TAR), and electronic medical record over a period of 111 days showed a lack of consistent heart monitoring associated with this medication. Additionally, the monthly medication reviews from August 2024 to July 2025 did not include documented recommendations for heart monitoring or instructions for hold parameters and physician notification related to the antihypertensive medication. Interviews with nursing staff confirmed that monitoring should occur for antihypertensive medications and that the CP is expected to identify any lack of appropriate monitoring. The facility's policy on Pharmacy Services and Medication Regimen Review requires oversight by a licensed pharmacist to maintain residents' well-being and prevent adverse medication consequences, but this oversight was not demonstrated in the case of the resident receiving Toprol XL.