Pharmacy Consultant Failed to Identify and Report Medication Monitoring Irregularities
Penalty
Summary
The Pharmacy Consultant (PC) failed to identify and report irregularities during the monthly drug regimen review (MRR) for two residents. For one resident with bipolar disorder, the PC did not ensure that there was monitoring for specific, measurable target behaviors related to the use of valproic acid, a psychotropic medication. The resident's records indicated a prescription for valproic acid to address extreme irritability affecting activities of daily living, with instructions to monitor episodes of irritability and aggression. However, the MRRs for May and June did not document any identified irregularities or report the lack of behavior monitoring to the attending physician or Director of Nursing (DON). For another resident with Parkinson Disease, the PC did not ensure monitoring for adverse effects associated with the use of carbidopa-levodopa. The care plan indicated a risk for adverse effects and the need for monitoring, but the Medication Administration Record (MAR) did not contain documentation of such monitoring. The MRRs for April, May, and June did not identify or report the absence of adverse effect monitoring to the attending physician or DON. During interviews, the PC acknowledged failing to identify and report the lack of appropriate monitoring for both residents in the monthly written reports. Facility policies and procedures required comprehensive MRRs, evaluation of medication therapy responses, and documentation and reporting of resident-specific irregularities or clinically significant risks to the DON and prescriber. The PC's failure to follow these requirements resulted in the deficiencies cited.