Consultant Pharmacist Failed to Identify and Report Medication Irregularities
Penalty
Summary
The facility's consultant pharmacist (CP) failed to identify and report medication irregularities during the monthly drug regimen review (MRR) for three residents. For one resident with alcoholic liver disease and portal hypertension, lactulose was prescribed for constipation, but the actual indication was for liver disease, as confirmed by the resident and hospital discharge summary. The facility's records and staff interviews revealed that the medication was being monitored for the wrong indication, and appropriate monitoring for liver disease was not conducted. The CP acknowledged not identifying or reporting this irregularity, stating her focus was on psychotropic medications. For two other residents prescribed glipizide for diabetes, the medication was not administered according to the manufacturer's specifications. One resident's glipizide was scheduled after breakfast instead of 30 minutes before a meal, as required for optimal effectiveness. The medication administration records confirmed that the drug was consistently given after breakfast. The second resident's glipizide was ordered to be given with meals but was administered at times inconsistent with the recommended timing, with doses given well after the scheduled meal times. Interviews with the Director of Nursing (DON) confirmed the improper administration times for glipizide and the lack of adherence to physician orders and manufacturer guidelines. The CP admitted that these issues had not been the focus of her recommendations and had not been identified as irregularities in her reviews. The facility's policies require the CP to assist in identifying medication-related issues and ensuring medications are administered to maximize effectiveness, but these requirements were not met in these cases.