Failure to Discontinue Medications as Per Physician's Orders
Penalty
Summary
The facility failed to ensure compliance with physicians' orders as recommended by the pharmacy for a resident. The resident was admitted to the facility and had a current Minimum Data Sheet (MDS) assessment score of 15. A pharmacy consultation report recommended discontinuing certain medications that promote gut health and normal functioning. The physician accepted this recommendation by signing the consultation. However, a review of the resident's active orders revealed that the medications were still being administered, as evidenced by the Medication Administration Record (MAR). The supplements were not discontinued as per the physician's orders, indicating a lapse in following through with the pharmacy's recommendations. During an interview, the Director of Nursing (DON) stated that the Unit Manager was responsible for making changes to the resident's orders after the doctor accepts or declines the pharmacy recommendation.
Plan Of Correction
Resident #48 had his discontinued on and Medication recommendations will be audited for of 2024 and the past 90 days to ensure compliance on by the DCS and facility pharmacist. If recommendations were identified as not followed through, they would be implemented at the time of the audit. The clinical services leadership team was educated on following pharmacy recommendations timely by the Regional Director of Clinical Services on. Pharmacy recommendations will be brought to QAPI monthly to review completion and for follow-up by the Director of clinical services/designee.