Failure to Identify and Report Drug Regimen Irregularities During Monthly Pharmacist Reviews
Penalty
Summary
A deficiency occurred when the Consultant Pharmacist failed to identify and report drug regimen irregularities for two residents during monthly medication reviews. For one resident with mild dementia, brief psychotic disorder, and anxiety, a PRN order for Haldol (haloperidol) was written for 60 days for agitation, with the diagnosis listed as dementia with agitation. The Consultant Pharmacist did not document any recommendations or irregularities regarding the inappropriate duration of the PRN antipsychotic order, which should have been limited to 14 days, nor did she question the diagnosis or the order, assuming it was acceptable due to the resident's hospice status. Interviews with facility staff revealed a lack of awareness about the 14-day limit for PRN antipsychotic medications and a reluctance to question hospice physician orders, even when the diagnosis or duration was incorrect. For another resident with unspecified dementia without behavioral or psychotic disturbances, physician orders were in place for olanzapine (an antipsychotic) and sertraline (an antidepressant), both prescribed for dementia without behaviors. The Consultant Pharmacist's monthly reviews did not document any recommendations or irregularities regarding the lack of appropriate diagnoses for these medications. Although the Pharmacist stated that a message was sent to the physician to review the diagnosis for sertraline, there was no documentation of this notification, and the issue with olanzapine was not addressed in a timely manner. The Physician Assistant confirmed that there were no current diagnoses of depression or psychosis for this resident, and the Assistant Director of Nursing acknowledged that the medications were prescribed without a mental health diagnosis. Throughout the review period, the Consultant Pharmacist did not consistently identify or report medication irregularities related to the indicated use and scheduled stop dates of antipsychotic and antidepressant medications for the two residents. Facility staff, including the DON and ADON, confirmed that medication orders were only checked monthly by the Consultant Pharmacist and that no recommendations or notifications regarding these irregularities were received. This lack of identification and reporting of drug regimen irregularities resulted in the continuation of inappropriate medication orders for both residents.