C2185

Pharmacist Failed to Identify and Report Medication Order Irregularity

Redding Post AcuteRedding, California Survey Completed on 10-22-2025

Summary

The facility's consultant pharmacist (CP) failed to identify and report an irregularity in a physician's order for cyclobenzaprine, a muscle relaxant, for a resident who was admitted with a left hip replacement and chronic pulmonary edema. The physician's order specified cyclobenzaprine 5 mg by mouth every eight hours as needed for pain and muscle spasms in both legs, but the medication administration record (MAR) did not document the specific indication—whether it was given for pain or muscle spasms—each time the medication was administered. The facility's policy required the CP to review medication orders monthly and report any irregularities, including medications without adequate monitoring, to the physician for review.

During the monthly medication regimen review, the CP did not identify or report the lack of documentation regarding the indication for cyclobenzaprine administration. In an interview, the CP acknowledged that there was no documentation indicating the reason for each administration of cyclobenzaprine and admitted this was a missed opportunity to catch the irregularity during the review. The deficiency was identified for one resident, and no irregularities were reported for cyclobenzaprine prior to the resident's discharge.

Penalty

No penalty information released