Failure to Document Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy review irregularities were properly addressed for one resident. According to facility policy, when a pharmacist makes a recommendation during the monthly drug regimen review, the physician or prescriber is required to review the recommendation, document any actions taken, and provide a rationale if no changes are made. For one resident, the pharmacist recommended considering a gradual dose reduction of Eszopiclone for insomnia and reevaluating the ongoing use of Cyclobenzaprine due to potential adverse effects. However, documentation showed only an illegible, undated initial and the word 'decline' for the Eszopiclone recommendation, with no evidence that the physician reviewed or addressed the recommendation, nor any rationale provided for declining it. Similarly, for the Cyclobenzaprine recommendation, the physician checked off that the recommendation was declined but did not provide a rationale in the resident's clinical record. Interviews with the DON confirmed the lack of proper documentation and physician response for both recommendations. These findings indicate that the facility did not follow its own policies and procedures for addressing pharmacy recommendations and documenting physician actions and rationales in the resident's health record.