Failure to Address Pharmacy Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a pharmacy recommendation for a resident. A quarterly Minimum Data Set (MDS) assessment for a resident, dated November 3, 2024, indicated that the resident was cognitively intact, required assistance for daily care needs, received routine and as-needed pain medication, and had a diagnosis of diabetes. A pharmacy Medication Regimen Review (MRR) recommendation, dated July 7, 2024, suggested that the physician consider ordering Senna, a stimulant laxative, once daily at bedtime while monitoring for signs and symptoms of constipation. However, there was no documented evidence that the physician reviewed or addressed this recommendation. An interview with the Director of Nursing on December 12, 2024, confirmed the lack of documented evidence that the physician addressed the pharmacy MRR for the resident, which should have been done according to the facility's policies and procedures.
Plan Of Correction
1. Physician to review medication recommendation with resident. 2. A baseline audit was completed for pharmacy recommendations. 3. The Director of Nursing/designee will educate nursing staff including agency on the process of following through with pharmacy recommendations. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks, then monthly for two months to ensure follow through of pharmacy recommendations. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.