Failure to Document Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician documented a review of pharmacy recommendations and follow-up actions for a resident, leading to potential medication side effects and unnecessary medications. The resident, who was cognitively intact, had several pharmacy recommendations that were not addressed by the physician. These recommendations included changing Lidoderm orders to PRN due to frequent refusals, re-evaluating the need for duplicate therapy with Elderberry Immune Complex and Vitamin C, and discontinuing Peri-Colace due to the use of Linzess. Further recommendations included improving glycemic control by adjusting insulin therapy and considering a gradual dose reduction of Zoloft, as required by federal nursing facility regulations. Despite these recommendations, the physician's response was left blank, with no signature or date, indicating a lack of follow-up on the pharmacy's suggestions. The facility's policy required that pharmacists report any irregularities to the attending physician, medical director, and director of nursing, with actions to be taken within specified timeframes. However, the physician did not review or sign the pharmacy recommendations for the resident, and the facility's nurse liaison acknowledged this oversight during an interview. This lack of documentation and follow-up on pharmacy recommendations resulted in a deficiency in medication management for the resident.
Plan Of Correction
Drug Regimen Review Element #1: Resident #15 has not had any negative outcomes related to observation. Resident #15's Pharmacy Recommendations have been reviewed by the facility provider, and new orders have been placed as deemed appropriate by the provider. Element #2: Residents residing in the facility have the potential to be affected. Element #3: The facility provider that is designated to complete Drug Regimen Review has been re-educated on the facility medication management policy. The medication management policy has been reviewed by the Director of Nursing and Administrator and deemed appropriate. Element #4: The Director of Nursing/designee will complete a random monthly audit on the completion of Drug Regimen Review recommendations. Variances will be corrected at the time of observation. Audits will be forwarded to the facility QAPI committee for further review and recommendations. Element #5: The Administrator is responsible for sustained compliance.