Failure to Identify and Report Drug Regimen Irregularities by Consultant Pharmacist
Penalty
Summary
The facility failed to ensure that the consultant pharmacist accurately identified and reported drug regimen irregularities for two residents who were prescribed antihypertensive medications with specific hold parameters. For one resident with end stage renal disease and hypertension, Coreg was ordered with instructions to hold the medication if systolic blood pressure (SBP) was less than 100, diastolic blood pressure (DBP) less than 60, or heart rate (HR) less than 60. Medication administration records (MARs) showed that the medication was held frequently throughout July and August due to low blood pressure or heart rate, but there was no documentation that the physician was notified of these repeated holds, nor were any recommendations made by the pharmacy consultant during monthly reviews. A second resident with hypertensive heart disease and heart failure was prescribed metoprolol succinate ER with similar hold parameters. The MARs indicated that this medication was also held multiple times when vital signs were outside the prescribed range. Again, the pharmacy consultant's monthly review did not identify or report these frequent holds as irregularities, and no recommendations were documented. Interviews with the DON and nursing staff confirmed that the medications were held according to parameters, but there was a lack of consistent physician notification and documentation. The pharmacy consultant acknowledged being unaware of the frequency with which these medications were held and stated that the review process would be modified. The administrator confirmed that there was no policy in place regarding the pharmacy consultant's responsibilities in this area.