Failure to Implement Physician-Agreed Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a physician-agreed medication regimen recommendation from the consultant pharmacist was implemented for one resident. The consultant pharmacist recommended that the resident receive vitamin D3, 1000 IU once daily, based on clinical guidelines for elderly individuals to maintain bone health. The attending physician reviewed this recommendation and documented agreement with the plan, indicating, "Agree; will do." However, a review of the resident's current physician orders revealed that no order for vitamin D3 had been entered. Interviews with facility staff, including the DON and a nurse practitioner, confirmed that the process for addressing pharmacy recommendations involves unit managers and the ADON updating the electronic medical record when a provider agrees to a recommendation. Despite this expectation, the agreed-upon order was not entered. The facility's policy requires that drug regimen review recommendations be acted upon, but in this case, the necessary follow-through did not occur, resulting in the deficiency.