Failure to Act on Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that medication regimen reviews were acted upon by a physician for five residents. The facility's policy requires that a clinical pharmacist reviews the residents' medication regimens and sends recommendations to the facility. The clinical nurse is then responsible for reviewing these recommendations and contacting the physician for further orders. However, for Residents 37, 43, 59, 75, and 84, there was no evidence in their clinical records that the recommendations made by the pharmacist were reviewed or addressed by the attending physician. The medication regimen reviews for these residents were completed on various dates, and recommendations were made, but the clinical records lacked documentation of the reviews, recommendations, or any actions taken by the physician. An interview with the Nursing Home Administrator confirmed that there was no evidence that the pharmacy recommendations were addressed by the physician, indicating a failure in the facility's process to ensure that medication regimen reviews are properly acted upon.
Plan Of Correction
1. Residents 37, 43, 59, 75, and 84 were reviewed by pharmacist. Recommendations forwarded to physician for review and orders were written as indicated/recommended. 2. Facility performed an audit of current residents' pharmacy recommendations completed to ensure physician reviewed and orders written as indicated/recommended. 3. Pharmacy consultant was requested by DON to send pharmacy recommendations to DON, then DON will print our recommendations and present to physician for review and written orders. 4. DON, or designee, will perform random weekly audits for 2 weeks, then monthly audits for 2 months to ensure pharmacy recommendations are completed by physician and orders entered as indicated. Results of audits will be presented at monthly Quality Assurance and Improvement Plan meetings for review and recommendations.