Failure to Act on Consultant Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that recommendations made by the consultant pharmacist during monthly drug regimen reviews were acted upon for two residents. For one resident, the consultant pharmacist recommended changing chewable Aspirin to a plain film-coated form that could be crushed and administered via NG-tube, as the current form was not suitable for crushing. Despite this recommendation, the resident continued to receive the chewable form, and the recommendation was not implemented, as confirmed by the DON upon review of the clinical record. For another resident, the consultant pharmacist identified duplicate therapy with Protonix and Pepcid and documented a note to the attending physician requesting evaluation of this issue. However, the note was not presented to the physician, and there was no evidence of a physician's response or signature. The facility's policy requires that resident-specific medication regimen review recommendations be documented and acted upon by the nursing care center and/or physician, which was not followed in these cases.