Failure to Implement Pharmacist's Recommendations for Insulin Management
Penalty
Summary
The facility failed to ensure that irregularities reported by the Pharmacist were acted upon for a resident reviewed for unnecessary medications. Specifically, the attending Physician agreed to the Pharmacist's recommendations to evaluate sliding scale insulin coverage and decrease finger sticks for blood glucose readings for a resident, but these recommendations were not implemented. The facility's policy requires that recommendations from the Pharmacist be acted upon and documented, but this was not done in this case. The resident involved had severe cognitive impairment and was receiving insulin injections. The Pharmacist recommended discontinuing sliding scale insulin and reducing fingerstick orders, which the attending Physician initially agreed to. However, the Physician later decided not to implement these changes due to clinical reasons, including the resident's history of episodes of high and low blood sugar, recent start of an oral diabetic medication, and recent removal of enteral tube feeding. The Physician did not document their rationale for not implementing the recommendations in the resident's medical record. Interviews with facility staff revealed that the nursing supervisors were responsible for reviewing the Medication Regimen Review forms and contacting the attending Physician, but they could not recall reviewing the recommendations for the resident. The Medical Director and Director of Nursing Services stated that the attending Physician should have documented their rationale for not implementing the Pharmacist's recommendations. This lack of documentation and action led to the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 I. Immediate Corrective Action The attending physician has reviewed the pharmacist’s Medication Regimen Review (MRR) recommendations dated 1/6/2025 and 2/5/2025 and provided retrospective clinical rationale for not implementing certain recommendations. II. Identification of other residents A facility-wide audit of all residents with pharmacist Medication Regimen Reviews completed within the past 90 days was initiated and completed on 3/30/2025. No negative findings resulted from this review. III. Systemic Changes The facility policy titled Medication Regimen Reviews was reviewed and found to be in compliance with the regulations. All providers will be educated on the requirement to follow through on agreed to pharmacist recommendations documented in the monthly Medication Regimen Review. The Director of Nursing (DON) or designee will verify that pharmacist recommendations are routed to the attending physician and that responses are tracked through a MRR Response Tracking Log. Attending physicians were provided written notification and guidelines reminding them of the regulatory requirement to act on pharmacist recommendations and document rationale if no change is made. IV. QA Monitoring An Audit Tool was developed to track compliance with the facility policy titled Medication Regimen Reviews. Audits will be conducted monthly by the Medical Director for three months. The audit includes: Verification that the attending physician reviewed and responded to each pharmacist recommendation. Confirmation that any agreed-upon recommendations were implemented and documented in the resident’s medical record. Identification of any discrepancies or lack of documentation of physician rationale. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Medical Director