Failure to Ensure Pharmacist Review and Implementation of Medication Monitoring and Dosage Recommendations
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the omission of required blood pressure or pulse monitoring prior to the administration of an antihypertensive beta blocker, Carvedilol, for a resident with multiple diagnoses including hypertension, aneurysm of the heart, traumatic brain injury, and transient ischemic attack. The resident had severely impaired cognition and required significant assistance with activities of daily living. The care plan directed staff to monitor for side effects of hypertensive medications and to obtain blood pressure readings as per protocol, but the physician's order for Carvedilol did not specify monitoring requirements, and the CP did not report this omission during monthly drug regimen reviews from April to November. Additionally, the facility did not implement the CP's recommendation regarding the dosage amount for Voltaren gel, a topical medication prescribed for pain. The physician's orders for Voltaren gel on multiple occasions lacked a specified dosage amount for application to the affected areas, particularly for the left shoulder. Although the CP made a recommendation for a dosage amount, the physician's response only addressed the lower extremity and did not specify a dosage for the upper extremity. This resulted in continued orders without clear dosage instructions for all prescribed sites. Interviews with staff revealed uncertainty regarding which antihypertensive medications required monitoring prior to administration, and acknowledgment that all topical medications, including Voltaren gel, require a specified dosage for administration. The facility was unable to provide a policy regarding pharmacy review when requested. These findings demonstrate failures in both the identification and reporting of medication regimen irregularities and the implementation of pharmacist recommendations.