Failure to Act on Pharmacy Recommendations for Medication Administration
Penalty
Summary
The facility failed to ensure that a physician acted timely upon irregularities identified by pharmacy services during drug regimen reviews for a resident. The resident, who was admitted with osteomyelitis and GERD, was prescribed sucralfate for GERD. A pharmacy note dated November 4, 2024, recommended altering the administration times of sucralfate to align with the manufacturer's instructions, which suggest administering the medication on an empty stomach prior to meals and at bedtime. However, the physician's response did not address this recommendation, and no changes were made to the medication administration times. The deficiency was identified during a review of clinical records, facility-provided medication information, and staff interviews. Despite the pharmacist's recommendation, the physician's order for sucralfate remained unchanged until January 9, 2025, when it was revised to include the recommended administration times. The Nursing Home Administrator confirmed the facility's responsibility to ensure timely action on pharmacy-identified irregularities, highlighting a lapse in the facility's compliance with this requirement.
Plan Of Correction
1. Resident 56 no longer resides at the facility. His medication order was revised to include pharmacist's recommendation prior to his discharge. 2. The facility will complete an audit of the most recent medication regimen reviews for all current residents, to ensure physician responses address the pharmacist's recommendation. 3. The DON/designee will educate physicians and their extenders on addressing pharmacy recommendations appropriately. 4. The DON/designee will perform monthly audits of sampled residents' medication regimen reviews to ensure appropriate responses were provided by physicians and physician extenders. Results will be reviewed at the facility's monthly QAPI meeting. Audits will continue until substantial compliance is reached.