F0756

D

Pharmacy Drug Regimen Review Recommendations for Antihypertensives Not Implemented

Claremore, Oklahoma Survey Completed on 12-18-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were implemented for a resident receiving antihypertensive medications. Facility policy titled "Drug Regimen Review-With Consultant Agreement only" (dated 2021) required that the drug regimen review include analysis of prescribed medications and nursing documentation, with findings and recommendations reported to leadership and nursing providing a written response within two weeks. For one resident with a diagnosis including hypertension, a physician’s order dated 09/05/25 for nifedipine ER 30 mg at bedtime for blood pressure did not include administration parameters. A subsequent Director of Nursing (DON) Report from pharmacy dated 09/17/25 documented a recommendation that the nifedipine order needed hold parameters, but the order was not updated to include them.

The same resident later had a physician’s order dated 09/19/25 for amlodipine besylate 5 mg once daily, and another order dated 11/25/25 for amlodipine besylate 10 mg once daily for hypertension, neither of which included administration parameters. A DON Report from pharmacy dated 10/08/25 again documented that the amlodipine order needed hold parameters, but this recommendation was also not implemented. During an interview on 12/17/25, the DON stated they were responsible for handling pharmacy reviews, providing those needing physician attention to the physician, and entering orders into the electronic record as needed. When reviewing the pharmacy recommendations for both nifedipine and amlodipine against the resident’s medication list, the DON acknowledged that both medications lacked parameters and stated they "must have missed it," confirming that the pharmacy’s recommendations for hold parameters were not followed.