Pharmacist Failed to Identify and Report Medication Monitoring Irregularities
Penalty
Summary
A deficiency occurred when the facility's consultant pharmacist failed to identify and report irregularities in the medication monitoring process for a resident prescribed metoprolol succinate for hypertension. The physician's order required the resident's pulse to be monitored and the medication to be held if the pulse was less than 60 beats per minute, with documentation of the pulse in the medical record. However, a review of the resident's Medication Administration Records (MAR) and Treatment Administration Records (TAR) over several months showed a lack of documentation regarding pulse measurements as ordered by the physician. Despite monthly medication regimen reviews by the consultant pharmacist, there was no evidence that the absence of required pulse documentation was identified or reported to the attending physician, medical director, or director of nursing. Interviews with facility staff confirmed that the MAR should have included a flagged area for documenting pulse and that the pharmacist was expected to review and identify such monitoring issues. The facility did not provide a policy addressing the pharmacist's responsibility to identify and report irregularities in medication monitoring outside of prescribed parameters.