Failure to Respond to Pharmacist's Recommendations on PRN Medications
Penalty
Summary
The facility failed to respond to the consultant pharmacist's recommendations regarding the medication regimens of a resident, identified as Resident 101. The pharmacist recommended limiting the duration of PRN lorazepam to 14 days or defining a specific length of therapy, as well as defining the length of therapy for PRN guaifenesin oral liquid. These recommendations were made on 11/30/2024 and 12/31/2024, respectively. However, the facility did not act upon these recommendations, as evidenced by the lack of new orders or documented responses to the pharmacist's suggestions. Resident 101, who was admitted with an anxiety disorder, was prescribed lorazepam and guaifenesin without defined durations, contrary to the facility's policy. The Director of Nursing acknowledged the failure to limit the duration of these PRN medications, which increased the risk of the resident receiving them inappropriately. The facility's policy required the attending physician to address the pharmacist's recommendations by their next scheduled visit, but this was not adhered to, leading to the deficiency.
Plan Of Correction
F756 Drug Regimen Review CFR(s): 483.45(c)(1) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The licensed nurse clarified Resident 101's use of Lorazepam PRN and the consultant pharmacist's recommendation from 11/24/2024 on 2/24/2025. Resident 101's use of guaifenesin oral liquid was discontinued on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents with consultant pharmacist recommendations that have not been responded to are potentially affected by the facility practice. The Director of Nursing requested a consultant pharmacist report on 2/28/2025 of recommendations that have not been responded to for the dates 11/1/2024 through 2/28/2025 to ensure the residents' physicians were contacted and a response was received. The consultant pharmacist provided a list of 0 residents recommendations requiring responses. All consultant pharmacist recommendations were completed. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Nursing revised the facility system for responding to the consultant pharmacist recommendations and filing the MRR in the resident record when an MRR is completed by the consultant pharmacist. The Director of Nursing receives and reviews the pharmacy recommendations from the pharmacist monthly. A copy of the MRR is maintained by month in the DON office. The Nurse Supervisor will receive a copy of the recommendations for timely completion. When completed, the nurse supervisor will file the MRR in the resident's record and provide a copy to the Director of Nursing for review. The Director of Nursing/designee will re-educate the licensed staff on or before 3/21/2025 on the facility policy and revised procedure, "Drug Regimen Review," emphasizing timely completion and filing in the resident's medical record. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Consultant Pharmacist completes medication regimen reviews monthly and provides a list of recommendations to the Director of Nursing. Recommendations from the prior month that remain outstanding are escalated in the report to the Director of Nursing for immediate completion. The Director of Nursing will monitor the completion of the MRR from the date of delivery until the recommendations are completed, including verification of required documentation. The Consultant Pharmacist will report trends identified in timely completion and filing of the MRRs to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement and to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. F757 Drug Regimen is free from Unnecessary Drugs. CFR(s): 483.45(d)(1)-(6) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 101's use of guaifenesin oral liquid was discontinued on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents receiving PRN medication without a duration, for a temporary condition such as a cough, are potentially affected by the facility practice. The Director of Medical Records generated an audit of all residents receiving guaifenesin oral liquid to identify residents whose medication does not have a stop date and are potentially affected by the facility practice. A copy of the audit was provided to the Director of Nursing on 2/27/2025 for further review and analysis.