Failure to Ensure Timely Physician Review of Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist recommendations from monthly medication regimen reviews were reviewed and acted upon by physicians in a timely manner for three of five residents reviewed. For one resident, the pharmacist recommended adjusting the timing of insulin lispro administration to align with meal times, and although the physician indicated agreement and signed the recommendation, the clinical record and medication administration record did not reflect any change to the order. For another resident, the pharmacist recommended ordering specific laboratory tests to monitor medication safety and efficacy, and while the physician wrote that the labs were ordered and signed the document, there was no corresponding physician order for the labs in the clinical record. Additionally, the pharmacist suggested changing the administration time of tamsulosin to after dinner for better absorption, but the physician disagreed with the recommendation, and the document was not signed or dated by the physician. For a third resident, the pharmacist recommended adding weekly blood pressure and pulse monitoring due to ongoing antihypertensive therapy. The document had an "OK" written on it, but lacked a physician signature or date, and there was no evidence in the clinical record that the recommendation was reviewed or acted upon. An interview with the Director of Nursing confirmed that there was no documentation showing that these recommendations were noted and completed. These findings indicate a failure to follow facility policy and regulatory requirements for timely physician review and documentation of pharmacist recommendations.