Failure to Act on Pharmacist Medication Regimen Review Diagnosis Irregularities
Penalty
Summary
The deficiency involves the facility’s failure to ensure that identified medication regimen irregularities were acted upon following monthly drug regimen reviews. Resident #5 was admitted with multiple diagnoses, including bipolar disorder, schizoaffective disorder, depression, end stage renal disease with dialysis dependence, orthostatic hypotension, and muscle weakness, and was cognitively intact per the admission MDS. Physician orders showed Midodrine 15 mg by mouth four times daily with an associated diagnosis of hypokalemia, and Lamotrigine 200 mg daily with an associated diagnosis of generalized muscle weakness, despite Midodrine being used for low blood pressure and Lamotrigine for epilepsy and bipolar disorder. The admission MDS documented active conditions including orthostatic hypotension, end stage renal disease/dialysis dependence, bipolar disorder, depression, psychotic disorder, and muscle weakness, and indicated the resident received antipsychotic, antidepressant, anticoagulant, opioid, and anticonvulsant medications during the assessment period. A new admission Drug Regimen Review dated 10/23/2025 by the consultant pharmacist recommended reviewing and updating diagnoses on the MAR for Simethicone, Lamotrigine, and PRN Loperamide; the NP signed the form and circled “Disagree” for all three drugs. Subsequent MRR summaries dated 11/30/2025 and 12/31/2025 documented that Midodrine and Lamotrigine, among other medications, required diagnosis review and MAR updates, and noted that “muscle weakness” was not a sufficient diagnosis for Lamotrigine; these forms were acknowledged by the NP, but the diagnoses were not corrected. In interviews, the NP acknowledged that hypokalemia was not the correct diagnosis for Midodrine, and that Lamotrigine was prescribed for bipolar disorder and should not have been linked to generalized muscle weakness, stating she had many patients and had not gotten around to updating the diagnoses. The Medical Director stated there was no facility policy establishing a timeframe for implementing MRR recommendations and that his expectation was that NPs would make necessary adjustments, with escalation to him if recommendations were not corrected. The consultant pharmacists indicated they sent monthly reports with recommendations to the DON, did not know the expectations for escalation, and one pharmacist stated the incorrect diagnoses would not have affected the resident’s medication or care and were not something she would have escalated to the Medical Director.
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