Consultant Pharmacist Failed to Identify Missing Monitoring for Medications With Hold Parameters
Penalty
Summary
A deficiency occurred when the consultant pharmacist failed to identify and report missing monitoring documentation for a resident receiving medications with hold parameters. The resident was admitted with paroxysmal atrial fibrillation, congestive heart failure, and hypertension, and had a physician’s order for digoxin 125 mcg by mouth in the evening with instructions to hold the dose if the pulse was below 60. The MAR showed digoxin was administered daily over several months, except on two days when the resident was absent, while the electronic health record showed numerous days in October, November, December, January, and February with no documented pulse. Despite this pattern, monthly drug regimen reviews dated in November, December, January, and February contained no recommendations related to digoxin or the lack of pulse documentation. The same resident also had a physician’s order for losartan 100 mg by mouth daily with a hold parameter if the systolic blood pressure was less than 110, and the MAR showed daily administration beginning in February. However, documentation of blood pressures for that month was limited to two dates, and the facility could not produce additional blood pressure records. During interviews, the consultant pharmacist and supervisor consultant pharmacist stated that the facility had not entered supplementary orders prompting nurses to document pulse with digoxin or blood pressure with losartan, and the supervisor explained that the consultant pharmacist was new and did not know how to check this in the system. The consultant pharmacist did not identify the lack of monitoring documentation during monthly reviews, while the physician stated she expected the pharmacist to notify the facility when hold parameters were not being monitored, and the administrator reported she was unaware that the consultant pharmacist did not know how to review hold parameter documentation.
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