Failure to Implement Pharmacy Review Recommendations
Summary
The facility failed to ensure that pharmacy review irregularities were implemented for two residents, R104 and R118. For Resident R104, a physician's order required that Nifedipine, an antihypertensive medication, be held if the systolic blood pressure was less than 100 or the heart rate was less than 60. However, the Consultant Pharmacist's review reports from December 2024 and January 2025 noted that the medication was not withheld on multiple occasions despite the heart rate being less than 60, as recorded in the medication administration record (MAR). This issue persisted into February 2025, indicating a repeated failure to adhere to the physician's hold order. For Resident R118, the facility did not complete a required assessment for medication self-administration, despite a recommendation from the pharmacy consultant report dated January 28, 2025. The absence of this assessment was confirmed during an interview with the Director of Nursing on February 21, 2025. These deficiencies highlight the facility's failure to implement pharmacy review recommendations and ensure proper medication management for the residents involved.
Penalty
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Surveyors found that staff declined pharmacy recommendations for gradual dose reductions of psychotropic medications for two residents without providing required patient-specific rationales. In both cases, the attending physician either left the rationale section blank or cited only a family request, contrary to facility policy and regulatory requirements.
A resident with multiple complex diagnoses and severe cognitive impairment did not have a pharmacist's medication regimen review recommendation regarding antipsychotic use reported to or acted upon by the medical provider in a timely manner. The recommendation was not acknowledged or reviewed by the provider until several months after it was made, contrary to facility policy requiring timely physician response and documentation.
Facility staff did not ensure that monthly medication regimen reviews were completed by a pharmacist and that recommendations were reported to and acted upon by providers in a timely manner for several residents with complex medical needs. Documentation of provider review and action on pharmacist recommendations was delayed or missing, and some reviews were not completed for multiple months.
Facility staff did not document a physician's response to pharmacist recommendations for a resident with multiple chronic conditions, including suggestions regarding prolonged antibiotic use and a dose reduction for Protonix. Despite facility policy requiring documentation of actions taken or explanations for disagreement, no such documentation was found for two separate MRRs.
A resident with multiple chronic conditions did not receive a required monthly drug regimen review by a licensed pharmacist, and there was no evidence that a medical provider reviewed pharmacy recommendations as outlined in facility policy. The resident's care plan called for routine pharmacy review due to psychoactive medication use, but documentation and staff interviews confirmed the review was missed and recommendations were not properly addressed.
The facility did not ensure that monthly medication regimen reviews were completed by a pharmacist for several residents, and failed to ensure that physicians responded to pharmacist recommendations for medication changes. For multiple residents, there was missing documentation of required reviews and unaddressed pharmacy recommendations for dose reductions of psychoactive and anticonvulsant medications, contrary to facility policy.
Failure to Document Rationale for Declining Pharmacy Recommendations for Psychotropic Medication Dose Reductions
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's recommendations for gradual dose reductions (GDR) of psychotropic medications were properly addressed and documented for two residents. In the first case, a resident with significant cognitive impairment and multiple psychotropic medications had pharmacy recommendations for GDRs, but the attending physician declined these recommendations without providing a patient-specific rationale, as required by facility policy. The physician simply checked a box indicating that a GDR was clinically contraindicated but left the rationale section blank. Additionally, the facility was unable to provide documentation of a previous pharmacy recommendation for this resident, despite requests from surveyors. In the second case, another resident with dementia, major depression, and mood disorder was prescribed Seroquel for mood disorder. The pharmacy recommended GDRs on two occasions, but the physician declined these recommendations. On one occasion, the only rationale provided was a family request, and on the other, no rationale was documented at all. Facility policy and the State Operations Manual require that a specific explanation be provided when recommendations are rejected, but this was not done. Both cases demonstrate that the facility did not follow its own policies and procedures regarding medication regimen reviews and the documentation of physician decisions related to pharmacy recommendations. The lack of patient-specific rationales for declining GDRs and the absence of required documentation were directly observed and confirmed through staff interviews, clinical record reviews, and facility documentation.
Delayed Medical Provider Review of Pharmacist Medication Regimen Recommendation
Penalty
Summary
Facility staff failed to ensure that a medication regimen review (MRR) completed by a licensed pharmacist was reported to and acted upon by the medical provider in a timely manner for one resident. The pharmacist completed the MRR and made recommendations regarding the resident's antipsychotic medication, specifically suggesting an evaluation and possible dose reduction of Olanzapine. However, the recommendation report was not found in the resident's clinical record, and there was no evidence that the medical provider had acknowledged or reviewed the recommendation until three months after the MRR was completed. The resident involved had multiple complex diagnoses, including hypertension, Alzheimer's disease with early onset, chronic respiratory failure, cerebrovascular disease, diabetes, epilepsy, depression, anxiety, dementia, chronic kidney disease, and schizoaffective disorder. The resident was also noted to have severe cognitive impairment. Facility policy required timely physician response to pharmacist recommendations, and documentation of review in the medical record, but these steps were not followed in this instance.
Failure to Complete and Act Upon Medication Regimen Reviews
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews (MRRs) were completed by a licensed pharmacist and that recommendations from these reviews were reported to and acted upon by medical providers in a timely manner for multiple residents. For one resident with multiple complex diagnoses, including progressive multifocal leukoencephalopathy and chronic kidney disease, the MRR completed by the pharmacist was not acknowledged or signed by a medical provider until well after the recommendation was made. The recommendation involved evaluating the use of multiple antidepressants and considering a dose reduction, but documentation of timely provider review and action was lacking. Another resident with severe cognitive impairment and multiple chronic conditions did not have evidence of MRRs being completed for several consecutive months. When MRRs were completed, the reports and recommendations were not promptly available in the clinical record, and provider responses were delayed. Recommendations included monitoring thyroid therapy and clarifying medication stop dates, but provider acknowledgment and action were not documented until weeks after the pharmacist's recommendations. A third resident with severe cognitive impairment had a pharmacist's recommendation for a dose reduction of Depakote that was not addressed by the medical provider for several months. The facility's policy required that MRR irregularities be reported and acted upon, but documentation showed significant delays in provider response and action. These deficiencies were confirmed through staff interviews, clinical record reviews, and facility policy review, with no additional information provided to the survey team prior to exit.
Failure to Document Physician Response to Pharmacist Recommendations
Penalty
Summary
Facility staff failed to document a physician's response to pharmacist recommendations made during the monthly Medication Regimen Review (MRR) for one resident. Specifically, recommendations from the pharmacist regarding the prolonged use of antibiotics (Fluconazole and Ketoconazole) and a suggested dose reduction for Protonix were not addressed or documented by the physician. The facility's policy requires that recommendations from the pharmacist be acted upon and documented by staff or the prescriber, with either acceptance and action or a documented explanation for disagreement. The resident involved had multiple diagnoses, including diabetes mellitus, congestive heart failure, seizures, and chronic respiratory failure with hypoxia, and was not cognitively impaired according to the most recent assessment. Despite the facility's established process for reviewing and responding to MRR recommendations, there was no evidence in the clinical record or facility documentation that the physician responded to the pharmacist's recommendations for this resident on two separate occasions.
Failure to Complete and Document Monthly Drug Regimen Review
Penalty
Summary
Facility staff failed to ensure that a licensed pharmacist performed a monthly drug regimen review for one resident, as required. Specifically, there was no evidence that a drug regimen review was completed for the resident in January 2025, and the facility was unable to provide documentation of a medical provider's review of the pharmacist's recommendations from July 2024. The July 2024 drug regimen review included a clinical priority recommendation regarding the concomitant use of daptomycin and atorvastatin, but the recommendation was not signed by the medical provider and was not found in the resident's clinical record. The resident involved had multiple diagnoses, including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Obstructive and Reflux Uropathy, Anxiety Disorder, and Major Depressive Disorder, and was assessed as cognitively intact. The resident's care plan included pharmacy review of psychoactive medication use as a routine intervention. Despite this, the facility's documentation and staff interviews confirmed that the required monthly drug regimen review was missed for January 2025, and the process for ensuring provider review of pharmacy recommendations was not followed according to facility policy.
Failure to Complete and Act Upon Monthly Pharmacy Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews for all residents as required, and did not ensure that physicians responded to pharmacist recommendations in a timely manner. For one resident, there was no evidence of monthly medication regimen reviews by the pharmacist in two separate months, and the attending physician did not respond to pharmacist recommendations regarding dose reductions for multiple medications across several months. The director of nursing reported that the pharmacist reviews residents deemed necessary and communicates urgent concerns, but there was no established process to ensure all required reviews were completed or that physician responses were documented and followed up. Another resident's clinical record also lacked evidence of monthly medication regimen reviews for two months. The director of nursing confirmed that there was no process in place to ensure completion of all required reviews. Additionally, for a third resident, the facility staff failed to act upon pharmacy recommendations for gradual dose reductions of antianxiety and anticonvulsant medications. The clinical record did not contain documentation of monthly pharmacy reviews for the past year, and recommendations made by the pharmacist were not addressed or documented by the physician, with some recommendations left blank and progress notes predating the recommendations. Facility policy requires the consultant pharmacist to perform monthly medication regimen reviews for every resident and to report irregularities to the attending physician, medical director, and director of nursing. The policy also requires that these reports be acted upon and that the physician document their review and any actions taken in the resident's medical record. However, the facility did not provide evidence that these requirements were consistently met for the residents reviewed during the survey.
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