Failure to Act on Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to ensure that the licensed pharmacist's report of medication irregularities was reviewed and acted upon in a timely manner for two residents. Resident 29, who had diagnoses including hypertension and anxiety disorder, was prescribed Quetiapine Fumarate for anxiety, depression, and insomnia. A Medication Regimen Review (MRR) conducted on August 11, 2024, recommended a trial dose reduction of Seroquel. However, the recommendation was not signed by the physician until October 31, 2024, and was never implemented as of January 14, 2025. The Director of Nursing (DON) expressed that the MRR should have been responded to and implemented timely. Similarly, Resident 74, diagnosed with major depressive disorder, anxiety disorder, and dementia, was prescribed Quetiapine Fumarate for depression. An MRR on August 8, 2024, recommended evaluating the routine antipsychotic use for potential dose reduction or discontinuation, and another MRR on August 11, 2024, suggested a trial dose reduction. The physician agreed with the recommendation on October 29, 2024, but the recommendation was not implemented by January 14, 2025. The DON indicated that MRRs should be reviewed and implemented timely by nursing and/or the physician.
Plan Of Correction
DRR for resident 29 with date of 8/11/24 was reviewed by MD and order was placed. DRR for resident 74 with date of 8/8/24 and 8/11/24 were reviewed by MD and orders placed. A Comprehensive review of DRR for the last 2 months will be reviewed to ensure that the MD has reviewed and any new orders implemented. The facility will take further steps to ensure that the problem does not re-occur by in-servicing Unit managers / RN Supervisors on F Tag 756 and facility policy "Medication Regimen Review". Compliance will be monitored by the Director of Nursing / Designee through the DRR Audit of 5 residents weekly x 3 weeks then monthly x 2 months to ensure that the DRR recommendations were reviewed with MD and acted upon, with audit results being forwarded to the QAA committee to determine the need for further follow up / monitoring.