Failure to Implement Pharmacist Recommendations for Medication Changes and Lab Monitoring
Penalty
Summary
The facility failed to act upon pharmacist recommendations in a timely manner for two of five sampled residents, as required by their own Pharmacy Recommendations policy and procedure. The policy states that medication regimen reviews (MRRs) are to be conducted for residents experiencing an acute change of condition, with recommendations communicated to the physician, medical director, and DON. In the case of one resident, the pharmacist recommended discontinuing several medications potentially contributing to recent falls, including tizanidine and atorvastatin. The physician reviewed and agreed with the recommendations, indicating that these medications should be discontinued. However, the medications were not discontinued, and the resident continued to receive them as per the physician's orders and medication administration record. For another resident, the pharmacist identified that the combination of sertraline, olanzapine, and tramadol could contribute to or worsen hyponatremia or SIADH, especially since the resident's most recent sodium level was slightly below normal. The pharmacist recommended obtaining a serum sodium level at the next convenient lab day and periodically thereafter. The primary care provider agreed with this recommendation, but there was no documentation in the electronic medical record that the sodium level was ordered or obtained. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for entering and following up on physician orders in response to pharmacist recommendations. The DON and PCP both described a process where either the physician or nursing staff could enter orders into the EMR, but acknowledged that communication lapses sometimes resulted in recommendations not being implemented. This led to the failure to discontinue medications for one resident and the failure to obtain recommended lab work for another.