F0756

D

Failure to Communicate Pharmacist’s Recommendation to Clarify Carvedilol Order

Windsor, North Carolina Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that the attending physician was informed of a consultant pharmacist’s recommendation to clarify a carvedilol order for a resident reviewed for unnecessary medications. The resident was admitted with hypertension and heart failure, and a cardiology consultation documented coronary and peripheral artery disease. The cardiologist’s documentation contained conflicting instructions: a handwritten recommendation to increase carvedilol to 37.5 mg twice daily, an after-visit summary stating 3.125 mg twice daily, and a medication list specifying 37.5 mg in the morning and evening. The facility’s admission order, entered by a nurse, was for carvedilol 3.125 mg twice daily, representing a significant decrease from the resident’s prior 25 mg twice daily dose.

During the monthly medication regimen review on 12/8/25, the consultant pharmacist identified the discrepancy between the prior 25 mg twice daily dose, the cardiologist’s recommendation to increase to 37.5 mg twice daily, and the facility’s order for 3.125 mg twice daily. The pharmacist documented a recommendation to clarify the carvedilol dose and order on the MAR and reported sending this recommendation by email to the DON on the same date. The DON acknowledged that she did not check her email daily, had not reviewed the December medication regimen reviews, and was unaware of the recommendation until 1/7/26, and therefore did not forward it to a provider. The NP and Medical Director both reported they had not received the pharmacy recommendation and indicated they would have addressed it if it had been provided to them, with the Medical Director stating it should not have taken a month for him to receive such a recommendation.