Failure to Act on Pharmacist Medication Review and Lab Orders
Penalty
Summary
The facility failed to act upon the pharmacist's monthly medication regimen review (MRR) for a resident with diagnoses including diabetes mellitus, end-stage renal disease, and anxiety. The resident's care plan included the use of antidepressant and antianxiety medications, but lacked documentation of non-pharmacological interventions. The MRRs for multiple months indicated irregularities and referenced reports, but the electronic health record (EHR) did not contain the actual reports or any documented responses from the physician or nursing staff. Additionally, the pharmacist requested a hemoglobin A1c (HbA1c) lab draw to monitor diabetes management, but the lab was not completed as ordered, and the last available result was outdated. Interviews with administrative nursing staff revealed that the resident refused lab draws at the facility, expecting them to be completed at the dialysis center, which did not occur. The administrative nurse was unable to locate the missing MRRs and confirmed that follow-up on the pharmacist's recommendations was not documented. Facility policy required that irregularity reports be provided to the physician for review and that any actions or rationale for no change be documented, but this process was not followed for the resident in question.