Lack of Physician Documentation for Not Following Pharmacy Medication Monitoring Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician documented the rationale for not implementing a pharmacy recommendation regarding medication monitoring for a resident. The resident, who had vascular dementia and catatonic schizophrenia, was prescribed carbamazepine as a mood stabilizer. The consultant pharmacist recommended obtaining a baseline carbamazepine level and periodic monitoring to optimize efficacy and reduce toxicity, as well as other laboratory tests. While the physician responded to the pharmacist's recommendation by ordering CBC, CMP, and ophthalmology follow-up, there was no documentation or explanation in the medical record as to why the carbamazepine level was not obtained as recommended. Record review and interviews confirmed that the rationale for not following the pharmacy's recommendation was not documented by the attending physician at the time. The DON reported that the nurse practitioner stated carbamazepine levels were not necessary since the medication was being used for catatonic schizophrenia rather than seizures, but this explanation was not entered into the medical record until an addendum was made after the issue was identified. The lack of timely documentation of the physician's rationale constituted the deficiency.