Failure to Document Physician Review of Pharmacy-Identified Drug Regimen Irregularities
Penalty
Summary
The facility failed to provide documentation that the attending physician reviewed irregularities identified by the pharmacist during monthly drug regimen reviews for two residents. For one resident, there were four dates on which the pharmacist identified irregularities, but the facility was only able to locate documentation for one of those dates. The remaining records could not be found, and there was no proof that the reviews were completed or seen by the appropriate discipline. The facility's own policy requires that the pharmacist communicate irregularities in writing to the attending physician, medical director, and DON, and that these communications become a permanent part of the resident's medical record. For another resident, two dates were identified where the pharmacist noted irregularities and made recommendations, but the facility could not provide the corresponding reports in the resident's chart. The DON stated that the pharmacist sends consultation reports via email, which are then printed and given to unit managers to follow up with physicians. However, the DON was unable to find the reports or confirm whether the physician had reviewed or addressed the irregularities. No additional documentation was provided to show that the irregularities were addressed by the physician.