Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified during the Monthly Drug Regimen Review (MDRR) by the facility's pharmacist were acted upon for one resident. Specifically, the pharmacist made recommendations regarding the continued use of gastrointestinal medications (Famotidine and Pantoprazole), the reconsideration of Simvastatin, and a gradual dose reduction for the antipsychotic medication Seroquel. In each instance, there was no documentation that the resident's physician was informed of the pharmacist's recommendations or that any action was taken in response. Record reviews showed that the pharmacist's notes to the attending physician regarding these medications were left blank in the section for the physician's response, indicating no documented agreement or disagreement with the recommendations. Interviews with facility staff, including a hospice RN, RN supervisor, and the DON, confirmed that the pharmacist's recommendations were not communicated to the physician as required. The facility's policy states that such irregularities should be reported to the physician within a specified timeframe and that the physician should document their review and actions taken. The resident involved had significant cognitive impairment and multiple diagnoses, including dementia with psychotic disturbances, anxiety, and depression. The lack of follow-through on the pharmacist's recommendations resulted in the potential for unnecessary medication administration, as there was no evidence that the physician was made aware of or addressed the identified medication irregularities.