Consultant Pharmacist Failed to Identify and Report Medication Order Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities in a resident's medication regimen. Specifically, the CP did not note the absence of indications for administration on physician orders for several medications, including Ursodiol, Tamsulosin, and Cymbalta. Additionally, the CP did not identify or report that the physician's order for Metoprolol, an antihypertensive medication, required heart rate monitoring prior to administration, and that this monitoring was not documented as completed for 61 out of 100 days reviewed. The Monthly Medication Reviews (MMRs) over a one-year period did not reflect that these irregularities were identified or reported by the CP. The resident involved had diagnoses including hypertension, major depressive disorder, gallbladder calculus, and diabetes mellitus, and was receiving multiple classes of medications such as anticoagulants, antidepressants, antianxiety agents, antiplatelets, diuretics, opioids, and hypoglycemics. Interviews with nursing staff confirmed that all medications should have an indication for administration and that specific monitoring parameters ordered by the physician should be followed. The facility's policy required the CP to review medication regimens and report irregularities, but this was not done in the case reviewed.