Failure to Timely Implement Pharmacy Lab Recommendations
Penalty
Summary
The facility failed to timely implement pharmacy recommendations for one resident reviewed for medications. The resident, who had diagnoses including fracture of the superior rim of the right pubis, major depressive disorder, anxiety disorder, and Alzheimer's disease, was noted to have cognitive impairment. The monthly medication review recommended laboratory tests including magnesium, complete metabolic panel (CMP), thyroid stimulation hormone (TSH), and complete blood count (CBC). However, there was no evidence in the physician orders that these labs were ordered following the pharmacy's recommendations. Orders for some labs were only placed later in response to new symptoms, and the TSH was not ordered until several months after the initial recommendation. This was confirmed by a corporate RN who verified that the labs were not completed as recommended.