Consultant Pharmacist Failed to Identify and Report PRN Lorazepam Order Irregularity
Penalty
Summary
A Consultant Pharmacist failed to identify and report a drug regimen irregularity for one of five residents reviewed for unnecessary medications. The resident in question was admitted with an anxiety disorder and had severely impaired cognition. Physician orders included both a PRN (as needed) lorazepam 0.5 mg every 4 hours for anxiety and a scheduled lorazepam 0.5 mg four times daily, both initiated on the same date. The PRN lorazepam order did not have a stop date and remained active in the electronic health record, although it had not been administered since the scheduled lorazepam was started. During the monthly Medication Regimen Review, the Consultant Pharmacist did not make any recommendations regarding the lack of a stop date for the PRN lorazepam order, despite being aware of CMS guidelines requiring such a stop date. Interviews with facility staff, including the DON and Administrator, confirmed their expectation that the Consultant Pharmacist would identify and report such irregularities. The Consultant Pharmacist acknowledged the oversight and could not explain why a recommendation was not made.