Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to act in a timely manner on the consultant pharmacist's recommendation regarding a resident's medication regimen. Specifically, a resident with diagnoses including psychosis, bipolar disorder, and diabetes mellitus was started on Olanzapine for psychosis manifested by constant worrying about a medical condition. The consultant pharmacist reviewed the medication regimen and recommended that the physician clarify and update the order for Olanzapine with appropriate behavioral indications. However, there was no documentation that the nursing staff followed up with the physician to address this recommendation or to clarify the behavioral manifestations justifying the use of the psychotropic medication. The resident's clinical records did not show any action taken by the licensed nursing staff to discuss or implement the pharmacist's recommendation, despite the psychiatrist evaluating the resident shortly after the recommendation was made. The facility's policy required that recommendations from the consultant pharmacist be acted upon and documented by staff or the prescriber, but this was not done. As a result, the resident was at risk for receiving unnecessary medication due to the lack of timely follow-up and documentation.