HospitalInspections.org

Based on interview and record review the facility's pharmacy failed ensure that medications were administered as ordered when a patient was not administered medications for pulmonary hypertension for three days. (Patient #1)

Findings Include:

Review of Patient #1' Medical Records reflected an 85 year old male admitted on 11/1/16 with a diagnosis of intestinal blockage and a past medical history of Pulmonary Hypertension, which if left untreated places him at a high risk for Congestive Heart Failure.

Review of Patient #1's History and Physical dated 11/1/16 reflected his home medications list included Lasix 40 mg daily, Adcirca 20 mg daily and Opsumit 10 mg daily, used for Pulmonary Hypertension.

Review of Patient Vincent Gardner's History and Physical reflected an 85 year old male re-admitted on 11/5/16 with a diagnosis of Congestive Heart Failure. "The patient was discharged home and then almost immediately returned to the ER with a new complaint of shortness of breath. According to the patient, the patient had been getting up and ambulating minimally in the room during the hospitalization for a small bowel obstruction and by the time he got home and was trying to actually do general chores and activities, he was profoundly short of breath....Plan: All other home medications will be continued including...Adcirca and Opsumit, his pulmonary hypertension medications..."

Review of Patient #1's Physician's Orders dated 11/5/16 reflected Adcirca 20 mg daily and Opsumit 10 mg daily were ordered but were not administered during his stay.

Review of Patient #1's Medical Administration Records dated 11/5/16 to 11/8/16 reflected the Adcirca and Opsumit had been suspended on 11/6/16, 11/7/16 and 11/8/16 by the pharmacy department.

During an interview on 4/ 12/17 in the facility conference room Staff #9, Pharmacy Director stated, "...the nurse and the pharmacy are aware the medication has been suspended....Normal process would be to contact the doctor or we contact the patient to ask them to bring in their home medications....If we don't have the medication in the formulary we will contact the doctor or replace with the automatic therapeutic interchange....The clinical pharmacist will review the medications...we don't do a chemical review of the medications on the weekends...."

During a telephone interview, on 4/11/17, Patient #1 stated, "...I take medications for my Pulmonary Hypertension. They are very expensive ...I wasn't asked to bring them in...they just didn't give them to me....right before I was discharge they said it wasn't in their formulary ..."

Review of the facility provided policy Hospital Drug Formulary (dated 6/20/12) reflected "...ii. The formulary will be broadly constructed and maintained in such a way that the need for use of 'non-formulary drugs' is minimized. It is recognized that on occasion the use of a 'non-formulary' drug may be indicated for a particular patient. The Pharmacy and Therapeutics Committee will develop guidelines for the provision of 'non-formulary' drugs and review the use of non-formulary drugs...."