Pharmacist Failed to Identify and Report Medication Monitoring Irregularity
Penalty
Summary
A deficiency was identified when a licensed pharmacist failed to report medication irregularities for a resident admitted with hypertension. The resident had physician's orders for Metoprolol Succinate ER 50 mg, with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 100 or if the apical pulse (AP) was below a certain threshold. Record review showed that, over several months, there was no documentation that the resident's blood pressure or apical pulse were checked prior to administering the medication, as required by the physician's orders. The pharmacist conducted monthly medication regimen reviews on three separate occasions but did not identify or report the lack of required monitoring documentation. Both the pharmacist and the Director of Nursing Services acknowledged during interviews that the irregularity was not identified or reported according to facility policy. This failure to recognize and report the medication administration irregularity constituted the deficiency.