Failure to Complete Pharmacy-Recommended Lab Orders After Medication Regimen Review
Penalty
Summary
The facility failed to ensure that irregularities identified by the consultant pharmacist during the monthly medication regimen review were completed for one resident. The resident, who had diagnoses including heart failure, dementia, and anxiety disorder, was noted to have severely impaired cognition and required staff assistance for activities of daily living. The consultant pharmacist made recommendations on two occasions for the physician to order specific laboratory tests, including a lipid panel and TSH levels. The physician agreed to these recommendations and signed off on them. However, documentation revealed that while the labs were eventually drawn following the second recommendation, there was no evidence that the labs were ordered or completed after the initial recommendation. Interviews with an LPN and the DON indicated that there was no consistent documentation or tracking system in place to confirm when labs were ordered, and the facility was unable to verify if the initial pharmacy recommendation had been acted upon. The facility's policy required staff to act upon all recommendations from the medication regimen review, but this was not followed in this instance.