Failure to Ensure Timely Pharmacist Review and Documentation of Medication Irregularities
Penalty
Summary
The facility failed to ensure that the consultant pharmacist consistently reported the results of monthly drug regimen reviews and that identified medication irregularities were properly addressed with documented physician rationale. For one resident, the consultant pharmacist's recommendations regarding the use of pantoprazole and zolpidem were disagreed with by the physician, but there was no documentation in the medical record providing a rationale for these decisions, as required by facility policy. The consultant pharmacist indicated that such rationales might be found in progress notes, but a review of the record did not reveal any such documentation. Additionally, the facility did not have evidence of a completed monthly medication regimen review for another resident for a specific month. The consultant pharmacist stated that the review was visible on her computer, but due to a system glitch, she was unable to provide a printed or electronic copy with the resident's name. The Director of Nursing confirmed that there was no documentation of the review in the facility or in the resident's electronic health record for that month. Interviews with facility staff, including the consultant pharmacist and nurse practitioner, revealed inconsistencies in understanding and documenting the requirements for medication regimen reviews and the handling of pharmacy recommendations, particularly regarding the need for stop dates and rationales for continued or PRN psychotropic medication orders. These lapses resulted in noncompliance with the facility's own policies and federal requirements for medication management and documentation.