Pharmacist Failed to Identify Lapse in Anticoagulant Therapy
Penalty
Summary
The facility's Consultant Pharmacist failed to identify and address a significant lapse in anticoagulant therapy for a resident with a history of atrial fibrillation, type 2 diabetes, and pulmonary embolus. Eliquis, an anticoagulant, was discontinued for a surgical procedure and not resumed for approximately three months. During this period, the Consultant Pharmacist conducted monthly drug regimen reviews but did not recommend restarting the medication or document any follow-up regarding its discontinuation, despite reviewing the resident's medical chart, provider notes, and laboratory results. Interviews with the Consultant Pharmacist, Medical Director, Nurse Practitioner, and Director of Nursing confirmed that the omission of Eliquis from the resident's medication regimen was not identified or addressed in the pharmacy reviews. The Medical Director and facility leadership acknowledged that the monthly pharmacy reviews should have detected the prolonged discontinuation and brought it to the attention of the medical team.