Pharmacist Failed to Identify Medication Errors Due to Incomplete Record Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a thorough monthly drug regimen review by not reviewing sufficient sections of a resident's medical record to identify significant medication errors. For one resident receiving behavioral health services, there were documented errors involving the administration of Ativan, including missed evening doses on seven occasions and the administration of an extra 0.5 mg dose on five occasions during the month reviewed. These discrepancies were identified through a review of both the drug control sheets, which were kept in a bound book on medication carts and not included in the electronic health record, and the Medication Administration Record (MAR). Further review revealed that there were duplicate active orders for Ativan, leading to confusion and incorrect dosing, with staff administering a total of 2.0 mg instead of the ordered 1.5 mg on certain days. The pharmacist responsible for the monthly medication regimen review completed the review remotely and did not identify these errors, as she relied on the recap summary and MAR, which she believed to be identical, and did not compare them with the drug control sheets. The pharmacist confirmed that the duplicate order did not appear on the summary she reviewed and acknowledged that she was not in the building to check the drug control sheets at the time of the review.