Failure to Address Pharmacist's Recommendation for Unnecessary Drug
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, as required by federal regulations. Specifically, the consultant pharmacist identified that the resident was receiving a long-acting medication without a stop date and recommended evaluating the current need and considering adding a stop date. The physician initially agreed to discontinue the medication but later disagreed, stating the medication was to be given as needed (PRN). Despite these recommendations and responses, the resident continued to receive the extended-release medication twice daily, as documented in the Medication Administration Records over an extended period. Interviews with facility staff, including the DON and a Nurse Practitioner, revealed that the process for addressing consultant pharmacist recommendations involved dividing the recommendations among unit managers and the ADON, with the expectation that any provider orders should be updated in the electronic medical record. The facility's policy required that drug regimen reviews be conducted monthly and that any irregularities be reported and acted upon, with documentation of the physician's review and actions taken. However, the records showed that the recommendations regarding the medication were not properly addressed or documented, resulting in the continued administration of the medication without adequate justification or a stop date.