Failure to Follow Up on Pharmacy Recommendations and Medication Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely follow-up on pharmacy recommendations for a resident reviewed for unnecessary medications. The resident, who had a history of stroke and was cognitively intact, had a pharmacy recommendation to discontinue fenofibrate and obtain a fasting lipid panel four weeks after discontinuation. Although the physician agreed with the recommendation and ordered the lab, the facility was unable to provide evidence that the lipid panel was completed as ordered. Additionally, the same resident was prescribed prophylactic antibiotics for urinary tract infection prevention. The pharmacy recommended discontinuing both nitrofurantoin and trimethoprim or documenting the intended duration of therapy. The physician referred the case to urology, but the resident did not attend the follow-up appointment, and there was no documentation of urology consultation regarding the continued use of antibiotics. The Director of Nursing was unable to explain the rationale for the resident being on two prophylactic antibiotics simultaneously.