Pharmacist Medication Recommendation Not Reviewed by Physician
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding a resident's medication regimen were reviewed and addressed by the physician. Specifically, a pharmacist recommended increasing the dosage of Metformin for a resident with multiple complex diagnoses, including end stage renal disease, heart failure, hypertension, anxiety, major depressive disorder, necrotizing fasciitis, overactive bladder, neuromuscular dysfunction of the bladder, and type 2 diabetes mellitus. The recommendation was documented in the pharmacist consultation report, but there was no evidence in the medical record, medication administration records, or progress notes that the physician or other prescribing provider reviewed or acted upon this recommendation. The resident in question had intact cognition and was receiving several medications, including hypoglycemics, antidepressants, diuretics, opioids, and anticonvulsants. Despite the pharmacist's recommendation to adjust the Metformin dosage, the medication order remained unchanged for several months, and no documentation was found indicating that the recommendation was considered by the medical staff. Additionally, the facility was unable to provide a policy related to monthly medication regimen reviews when requested.