Failure to Ensure Accurate Medication Regimen Review and Administration
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not conducting accurate Medication Regimen Reviews (MRR), not administering medications correctly, and not providing adequate medication monitoring. Specifically, a Licensed Practical Nurse (LPN) was observed administering Plavix, Furosemide, and Lokelma together to a resident on a dialysis day, without regard to manufacturer guidance that Plavix and other oral medications should be given at least two hours before or after Lokelma. The manufacturer's prescribing information for Lokelma indicates that co-administration can reduce the effectiveness of Plavix and increase systemic exposure to certain drugs like Furosemide, and that Lokelma contains sodium, which may cause edema. The resident involved had diagnoses of End Stage Kidney Disease, Stroke, and Diabetes, and had been receiving Plavix and Lokelma since November 2024. Medication Administration Records showed that Plavix and Lokelma were administered together three to four times weekly over several months. The consultant pharmacist's monthly reviews from January through July 2025 did not identify any concerns, and the facility's policies required medications to be administered according to professional standards and manufacturer specifications. Despite these requirements, the medication administration and review processes failed to identify or address the inappropriate timing of these medications.