Failure to Act on Pharmacist-Identified Medication Irregularity and Laboratory Monitoring
Penalty
Summary
A deficiency was identified when the facility failed to ensure that irregularities identified by the consultant pharmacist during a monthly medication regimen review were acted upon for a resident with dementia, psychotic disturbance, anxiety, and a history of falls. The medication regimen review on 4/4/25 noted that laboratory monitoring was required for the resident's Seroquel use, and there were no recent labs on file. The physician signed the review, indicating agreement to order the labs, but there was no documented evidence in the physician orders that the requested laboratory tests were actually ordered or obtained. Interviews with facility staff revealed that the LPN was aware of the pharmacist's recommendation and the physician's signature but confirmed that labs were not ordered and no results were available. The unit manager RN was unfamiliar with the medication regimen review documentation and confirmed there was no lab order or physician note regarding the labs. The DON reported contacting the physician, who stated the resident must have refused the labs, but there was no documentation of any refusal. This sequence of events resulted in the facility not following through on the pharmacist's identified irregularity and the agreed-upon physician action.