Failure to Follow Up on Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up and documentation of pharmacy consultant recommendations for one resident. Multiple monthly drug regimen reviews by the pharmacy consultant included recommendations regarding the continued use and reassessment of divalproex, clarification of prednisone dosing, and the addition of diagnoses for certain medications. In each instance, there was no documentation that the physician had been updated or had addressed the recommendations, nor was there evidence of physician signatures on the pharmacy reviews. The facility was unable to provide records showing that these recommendations were communicated to or acted upon by the physician within the required timeframe. The resident involved had an intact cognitive status and was independent with activities of daily living, with diagnoses including adjustment disorder with depressed mood, hypertension, diabetes, anxiety, orthostatic hypotension, repeated falls, and stroke. Interviews with the DON and nurse consultant confirmed the lack of an effective process for organizing and following up on pharmacy consultant medication reviews, as well as the absence of required documentation in the medical record. No relevant policy was provided by the facility during the survey period.