Failure to Document Rationale for Declining Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that physicians or prescribers documented the rationale for declining pharmacist recommendations regarding unnecessary medications for two residents. In both cases, the consultant pharmacist conducted monthly medication regimen reviews and made specific recommendations to reevaluate or discontinue certain medications due to potential risks or duplicative therapy. However, the physicians or nurse practitioner declined these recommendations without providing any documented rationale in the residents' medical records, despite signing the forms. For one resident, the pharmacist recommended reevaluating and possibly discontinuing nitrofurantoin, which had been used for urinary tract infection prophylaxis for several months, citing risks such as pulmonary fibrosis and hepatotoxicity. The physician declined the recommendation and signed the form but did not document any reason for this decision. In another case, a resident was receiving megestrol for appetite stimulation without a qualifying diagnosis, and the pharmacist recommended discontinuation due to limited benefit and potential adverse effects. The physician again declined without providing a rationale or signature. Additional recommendations to discontinue sucralfate and address duplicate beta-blocker therapy were also declined by the nurse practitioner without documented explanations. During an interview, the Director of Nursing confirmed that prescribers are expected to provide a rationale when declining pharmacist recommendations, but this was not done in these instances. Review of the facility's policy indicated that prescribers should document their rationale for rejecting pharmacist recommendations in the medical record, in accordance with CMS guidelines. The lack of documentation for the rationale behind declining these recommendations constituted the deficiency.