Consultant Pharmacist Failed to Identify Medication Irregularity During Review
Penalty
Summary
The Consultant Pharmacist failed to identify and report a medication irregularity during the monthly drug regimen review for a resident with major depressive disorder and moderately impaired cognition. The resident was prescribed Depakote 250 mg twice daily, which was later reduced to 125 mg twice daily for 14 days with instructions to discontinue due to the addition of Keppra. However, the order entered by the Director of Nursing did not include a 14-day stop date, resulting in the resident continuing to receive Depakote beyond the intended discontinuation period. The Medication Administration Record showed the resident received additional doses of Depakote after the 14-day period had elapsed. During the Consultant Pharmacist's monthly review, the medication change was noted, but no recommendations or identification of the irregularity were made. Interviews with the Psychiatrist and Physician confirmed that the Depakote should have been discontinued after 14 days, and the error was not detected by facility staff or the Consultant Pharmacist. The resident did not experience any reported adverse outcomes from the continued administration of Depakote, but the deficiency was identified for failing to follow proper medication regimen review and reporting procedures.