Failure to Act on Pharmacist's Recommendations
Penalty
Summary
Fair Acres Geriatric Center was found to be non-compliant with the requirements for drug regimen review as per 42 CFR 483.45(c). The facility failed to ensure that medication irregularities identified by a licensed pharmacist were acted upon by a physician for one of the residents reviewed. Specifically, the pharmacist's recommendations to discontinue certain medications and adjust the timing of another were not addressed by the attending physician. These recommendations included discontinuing D-Mannose due to ongoing urinary tract infections and potential effects on blood sugar, Melatonin due to concurrent use with Trazadone for insomnia, Glucosamine-Chondroitin due to uncontrolled pain, and PreserVision AREDS 2 due to duplication with another multivitamin. Additionally, a recommendation was made to change the timing of Omeprazole to optimize its effectiveness. The clinical record of the resident in question did not contain any documentation from the attending physician acknowledging or addressing these recommendations. During an interview, the Director of Nursing confirmed the absence of documented evidence of a physician's response to the pharmacist's recommendations. This lack of action and documentation constitutes a failure to comply with the federal and state regulations regarding drug regimen reviews and the necessary follow-up actions by the attending physician.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court finding. All residents receiving a Drug Regimen Review have the potential to be affected. Resident R134 was seen by the physician following the pharmacy recommendation that was reviewed by the physician on 10/9/24 on 10/21/24, 11/21/24, 12/20/2024, and 1/22/25. Resident R134 had drug regimen reviews completed on 11/6/24, 12/6/24, and 1/8/24 which did not have any additional recommendations for the physician. Medication Regimen Review Policy and Procedure was reviewed. The physicians were re-educated on the Medication Regimen Review Policy and Procedure. DON, or designee, will audit for documented evidence of a response to Drug Regimen Reviews. Audits will occur monthly x3. If trends are identified, corrective action, including a Root Cause Analysis, will be reported to the QA Committee.