Delayed Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely review of pharmacy recommendations by a physician for one of the sampled residents. Resident 41, who had diagnoses of anxiety and Alzheimer's disease, was prescribed melatonin and trazodone at bedtime. On August 1, 2024, a pharmacist recommended that the physician review the necessity of both medications and consider discontinuing melatonin to reduce the resident's medication load. However, there was no evidence that the physician addressed this recommendation until October 1, 2024, and the melatonin was not discontinued until October 2, 2024. During an interview on January 16, 2025, the Director of Nursing confirmed that pharmacy recommendations should be addressed by the physician within five to seven days, but acknowledged that this did not occur in the case of Resident 41.
Plan Of Correction
Unabe to retroactively correct for Resident 41. An audit of current resident's pharmacy recommendations over the last 30 days were reviewed to ensure they were presented to the provider for review. DON will be educated on the components of this regulation, with emphasis on ensuring pharmacy recommendations are addressed timely. DON/designee will perform audit of 5 pharmacy recommendations. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.