Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were acted upon in a timely manner for two residents. Resident 79, who was admitted with diagnoses including Parkinsonism, dementia, and depression, had pharmacy recommendations made on multiple occasions from June to November 2024. However, there was no documentation indicating what these recommendations were for June, July, August, or September, nor any evidence that they were addressed by the physician. Similarly, Resident 149, admitted with syncope, hypertension, and dementia, had pharmacy recommendations made in September and November 2024, but there was no documentation of these recommendations or any indication that they were addressed by the physician. In an interview, the Director of Nursing confirmed the absence of documentation regarding specific pharmacy recommendations or their timely action. This deficiency was identified under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Plan Of Correction
Residents 79 & 149 pharmacy recommendations have been reviewed by the physician. An initial audit will be completed by the Director of Nursing/Designee on Pharmacy recommendations since 11/1/24 to ensure recommendations have been reviewed by the MD/CRNP and recommendations followed in a timely manner. Licensed Nursing staff will be re-educated by the Director of Nursing or designee on ensuring pharmacy recommendations are reviewed with MD/CRNP and followed up on in a timely manner. The DON and/or designee will complete weekly random audits x90 days on pharmacy recommendations to ensure they were followed up on. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.