Failure to Provide Physician Oversight for Immunosuppressant Medication Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician or physician assistant (PA) provided adequate supervision and oversight for the care of a resident with a history of organ transplant who required daily tacrolimus, an immunosuppressant medication. After a hospitalization, the resident's medication regimen was changed, including a new dosing schedule for tacrolimus and a recommendation for follow-up laboratory monitoring. However, upon the resident's return to the facility, the updated tacrolimus regimen was not correctly identified or implemented by the facility's medical staff. The resident missed a total of 40 doses of tacrolimus over several weeks, as the medication was not prescribed from the time of readmission until nearly three weeks later. Additionally, the required follow-up tacrolimus level was not ordered on the recommended date, and when a tacrolimus level was eventually drawn and found to be low, there was no timely intervention or adjustment to the medication regimen. The PA reviewed the abnormal lab result but did not document any follow-up actions or new orders, and did not confirm whether the results were communicated to the resident's cardiologist as required. Progress notes from both the physician and PA failed to reflect the updated medication orders and monitoring recommendations from the hospital discharge summary. Both the physician and PA were unaware of the missed doses and abnormal lab results until notified by the resident's cardiology team. The facility's records did not show that the medical staff adequately reviewed or acted upon the hospital's recommendations, nor did they ensure that the resident's care was properly supervised according to facility policy.