Failure to Act on Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist (CP) were acted upon in a timely manner for two residents. Resident #54 was admitted with chronic obstructive pulmonary disease and was cognitively intact. The CP made several recommendations regarding the resident's medication regimen, including potential risks of serotonin syndrome and duplicate therapy, which were not addressed by the attending physician or reflected in the Medication Administration Record (MAR). These recommendations were made in June, August, September, and October, but none were completed by the facility. Resident #35, admitted with hemiplegia and hemiparesis following a stroke, had a discontinued order for a medication used to treat lung disease. The CP recommended discontinuing a PRN medication that had not been used for over 60 days, but this recommendation was not addressed in a timely manner. The Director of Nursing (DON) acknowledged that pharmacy consultant recommendations should be addressed within one to two weeks, but this was not done. The facility's policies required that CP reports be acted upon and submitted to the DON within 10 working days. However, the reports for both residents were not signed or dated by the attending physician, and the recommendations were not completed. The Licensed Nursing Home Administrator (LNHA) and other staff acknowledged the failure to address the pharmacy consultant recommendations timely, as per the facility's policies.
Plan Of Correction
1. Residents affected by the deficient practice: For residents #54 and #35, provider and nursing reviewed and addressed pharmacy consultant recommendations for six months for both residents. 2. Identifying other residents who could be affected by the deficient practice: All residents with recommendations from the pharmacy consultant are at risk if the Consultant Pharmacy Report is not followed up with in a timely manner. All pharmacy recommendations for December were audited by the Director of Nursing to confirm that provider and nursing recommendations were completed, with no issues noted. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Beginning on 12/6/24, Unit Managers and U.S. FOIA (b) (6) received education on Pharmacy Recommendations by Director of Nursing. Monthly Pharmacy recommendations are to be completed within one week of receiving from Pharmacy Consultant. DON/or designee will follow up to ensure all recommendations have been addressed by the Physician. 4. The Director of Nursing will review/ensure accurate completion of the Monthly Pharmacy Consultant reports x3 months and Quarterly x2. Results will be reviewed during Quality Assurance Meeting over the duration of the audit process to ensure compliance and reassessed for further action.