Pharmacist Failed to Identify and Report Medication Irregularities
Penalty
Summary
A licensed pharmacist failed to identify and report medication irregularities for three of eight sampled residents during monthly drug regimen reviews. For one resident with intact cognition and multiple diagnoses, including anxiety disorder and major depressive disorder, a PRN order for Ativan was initiated without an end date, and pharmacy reviews over several months did not note this irregularity or recommend provider follow-up. Another resident with moderate cognitive impairment and anxiety disorder had a PRN order for Clonazepam without an end date, which also went unaddressed in pharmacy reviews. A third resident, cognitively intact but requiring extensive assistance, had a long-standing antibiotic order for Minocycline without an end date or documented reassessment, and this was not identified as an irregularity by the pharmacist in monthly reviews. Interviews with the consulting pharmacist confirmed that these PRN psychotropic and antibiotic orders had not been reviewed for appropriate end dates or continued need, despite facility expectations and contractual obligations for the pharmacist to identify and report such irregularities. The facility's director of nursing and administrator stated that they rely on the pharmacist to bring such issues to their attention and to provide written documentation of any findings or recommendations, which did not occur in these cases.