Failure to Document Physician Response to Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations regarding medication regimen reviews were properly reviewed and implemented by the physician, or that the physician provided documentation with a patient-specific rationale for not following the recommendations. For two residents, the pharmacist had recommended gradual dose reductions (GDR) for medications including Doxepin, Prazosin, and Bupropion for one resident, and hydroxyzine and haloperidol for another. In these cases, the physician either did not provide a rationale for continuing the medications or failed to document that the recommendations were sent to outside providers for review. One resident had multiple psychiatric and sleep-related diagnoses and was receiving several medications for these conditions. The pharmacy made repeated recommendations for GDR, but the physician did not provide patient-specific reasons for continuing the medications, and there was no documentation that recommendations were communicated to the outside provider responsible for some of the prescriptions. The Director of Nursing (DON) confirmed that no rationale or follow-up was documented for these recommendations. Another resident with severe dementia, anxiety, and auditory hallucinations was prescribed hydroxyzine and PRN haloperidol. The pharmacy recommended a GDR for hydroxyzine and discontinuation or documentation for continued PRN use of haloperidol. The physician's responses were incomplete, lacking patient-specific rationale and anticipated duration of use for the PRN medication, and the haloperidol order did not have an end date. The DON confirmed the absence of required documentation in the medical record.