Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to maintain and address pharmacy recommendations for three residents, as required by §483.45(c) Drug Regimen Review. For Resident 23, a pharmacist's monthly medication review note dated June 10, 2024, indicated that a medication review was completed, but there was no evidence of the pharmacist's report of recommendations or a physician's response to these recommendations. The Nursing Home Administrator and Director of Nursing confirmed that the pharmacy recommendation for this date could not be located. Similarly, for Resident 49, a medication review was completed by the consultant pharmacist on November 10, 2024, but there was no documentation of the pharmacist's recommendations or any response from the physician or facility. For Resident 42, a pharmacist's review note also dated June 10, 2024, indicated a completed medication review with a directive to "see report for recommendation," yet no evidence of the pharmacist's report or physician's response was found. The Nursing Home Administrator and Director of Nursing confirmed the absence of the pharmacy recommendation for this date. These deficiencies were previously cited on February 16, 2024, and May 22, 2024.
Plan Of Correction
Cited: Residents 23, 42, and 49 pharmacy recommendations were reviewed by the physician with a response. • Like: The facility will complete a two-week look back to review pharmacy recommendations to ensure there is a physician response. • Education: DON/designee will educate the licensed staff to ensure responses are provided to pharmacy recommendations. • Audits: DON/designee will audit 5 resident pharmacy recommendations weekly x 4 weeks then monthly x 2 months to ensure physician response is provided. Results will be taken through QAPI.