Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physicians addressed pharmacy recommendations for three residents, leading to deficiencies in drug regimen reviews. For Resident 77, the consultant pharmacist identified irregularities in the medication regimen, including the prolonged use of Ativan without a stop date and the inappropriate timing of an activating antidepressant. Despite these recommendations, there was no documented evidence of physician review or response until several months later, indicating a significant delay in addressing the pharmacist's concerns. Resident 20's clinical records revealed multiple pharmacy recommendations for medication evaluations and dose reductions, which were not reviewed or responded to by the attending physician. These recommendations included evaluating medications for an annual dose reduction and assessing potential contributors to a fall. The lack of timely physician response to these recommendations highlights a failure in the facility's process for addressing pharmacist-identified irregularities. Similarly, Resident 63's records showed repeated pharmacy recommendations to reevaluate the use of methenamine and the combination of central nervous system active medications. Despite these recommendations, there was no documented physician response, indicating a failure to act on the pharmacist's advice. Interviews with facility staff confirmed the lack of documented evidence of physician review or response to the pharmacist's recommendations for all three residents.
Plan Of Correction
The pharmacy recommendations for residents 77, 20, and 63 were addressed by their attending physicians. A 30 day look back was completed to ensure that all pharmacy recommendations were addressed. The DON and ADON were educated on ensuring that pharmacy recommendations are addressed timely. The Administrator or designee will audit pharmacy recommendations monthly x2 to ensure they are addressed by a physician. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.