Failure to Implement Pharmacy Recommendations and Timely Lab Orders
Penalty
Summary
The facility failed to ensure timely review and implementation of Medication Regimen Reviews (MRRs) and pharmacy recommendations for one resident. The resident, who had diagnoses including diabetes mellitus type II, bipolar disorder, and anxiety, was cognitively intact as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). A pharmacy consultation recommended lab draws for A1C and magnesium levels, which the physician agreed to and signed. However, a review of the resident's medical records, medication and treatment administration records, and progress notes from October through December revealed that no labs were ordered or drawn, and there was no documentation of these labs being completed. Further review showed that a physician order for routine A1C labs was entered, but the required A1C lab for September was not scheduled or drawn, despite the last A1C being completed in March. The Director of Nursing (DON) acknowledged that lab draws were missed due to issues with order entry duration and communication lapses among travel nurses, resulting in the oversight. Additionally, a subsequent pharmacy consultation again requested updated lab values, but there was no evidence that this was addressed. Facility policy requires timely correction and documentation of pharmacy recommendations, which was not followed in this instance.