Failure to Address Pharmacist-Identified Medication Review Irregularity
Penalty
Summary
A deficiency occurred when the facility failed to address an irregularity identified by the pharmacist during the monthly medication review for one resident. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, Alzheimer's disease with early onset, anxiety disorder, major depressive disorder, dementia, and a history of falling, was receiving quetiapine and furosemide. The pharmacist recommended a Comprehensive Metabolic Panel (CMP) be completed immediately and every six months thereafter, as documented in the Medication Regimen Review (MRR) dated March 11, 2025. Although the physician signed off on this recommendation and a nurse indicated the order was faxed to the lab, there was no evidence that the lab order was actually entered or completed in March. A subsequent MRR in April noted that the CMP lab results were still missing and the order had not been entered. The advanced practice nurse signed off to schedule the lab for the next available day, and staff documented that the order was placed for April 23, 2025. However, review of the order summary confirmed that no CMP lab draw was ordered in March, and the order was not entered until April. The facility's policy requires staff to act upon all pharmacist recommendations according to established procedures, but this was not followed in this instance.