Failure to Discontinue Unnecessary Medication Following Pharmacy and Physician Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to implement a pharmacy recommendation and corresponding physician order regarding a resident's medication regimen. The resident, who had diagnoses including iron deficiency anemia, weakness, fibromyalgia, and Parkinson's disease, had been receiving ferrous sulfate 325 mg daily since 2023. A pharmacy review recommended discontinuing the ferrous sulfate after a normal complete blood count (CBC) was documented. The physician agreed with this recommendation and also noted to discontinue monthly CBC monitoring. However, a handwritten note from the DON indicated a misunderstanding, stating the resident was not on monthly CBCs and that the issue would be readdressed. Despite the physician's agreement to discontinue ferrous sulfate, medical record review showed that the medication was not discontinued and continued to be administered. The resident's orders and medication administration records confirmed ongoing administration of ferrous sulfate. Interviews with the physician and DON revealed miscommunication and misinterpretation of the pharmacy recommendation and physician's intent, resulting in the continued use of an unnecessary medication.