Consultant Pharmacist Failed to Identify Midodrine Dosing Outside Ordered Parameters
Penalty
Summary
A deficiency occurred when the Consultant Pharmacist failed to identify and report a medication irregularity during two consecutive monthly medication regimen reviews for one resident receiving midodrine for orthostatic hypotension. The resident had an order for midodrine 2.5 mg twice daily with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 120 mm/Hg or the diastolic blood pressure exceeded 80 mm/Hg. Review of the November medication administration record (MAR) showed multiple instances where midodrine was documented as administered despite SBP readings above the ordered parameter, including blood pressures of 124/53, 124/68, 129/54, and 129/56 mm/Hg. The Consultant Pharmacist’s November medication regimen review, dated 11/18/25, documented that there were no new irregularities and did not address these administrations outside the ordered parameters. In December, the MAR again showed repeated administrations of midodrine when the resident’s SBP exceeded the ordered hold parameter, with documented blood pressures such as 122/67, 121/66, 132/60, 121/60, 121/67, 122/61, 124/62, 128/61, 131/72, 139/74, 124/69, and 134/68 mm/Hg at the time the medication was signed as given by various nurses and medication aides. The Consultant Pharmacist’s December medication regimen review, dated 12/18/25, again stated there were no new irregularities and did not address the ongoing administration of midodrine outside the specified parameters. In a subsequent interview, the Consultant Pharmacist acknowledged that his monthly review process included checking current and prior MARs for medications given outside ordered parameters, stated that such doses should have been documented as held when outside parameters, and admitted that he should have addressed these irregularities but missed them due to human error. The DON confirmed that the Consultant Pharmacist was expected to identify such issues during the monthly reviews.
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