Failure to Act on Pharmacist Recommendations for Medication Dosing
Penalty
Summary
The facility failed to ensure that recommendations made by the licensed pharmacist regarding medication orders were reviewed and acted upon by the residents' physicians for two of five residents reviewed for unnecessary medications. Specifically, for two residents with diagnoses including knee pain, muscle weakness, and right shoulder pain, the pharmacist identified that the orders for Voltaren/diclofenac gel were not specific enough, lacking a clearly defined dose as recommended by the manufacturer. The pharmacist made recommendations on two separate occasions for each resident to clarify the dosing instructions, but the physicians either did not respond or disagreed with the recommendation without providing a revised order that included the required dosing information. Clinical record reviews showed that both residents continued to have medication orders for diclofenac gel that did not specify the dose to be administered, despite repeated pharmacist recommendations. The facility's policy required that such recommendations be acted upon and documented, and if the prescriber did not respond, further follow-up was to occur. During an interview, the Nursing Home Administrator confirmed that the physicians should have provided specific dosing orders for the medication, but this was not done.