Failure to Ensure Physician Review and Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and acted upon the recommendations made by the consulting pharmacist for multiple residents. In several instances, the pharmacist identified issues such as inappropriate medication diagnoses, the need for updated or clarified medication orders, and the necessity for specific monitoring related to psychoactive medications and anticoagulants. Despite these recommendations being documented in the residents' records, there was no evidence that the physician reviewed, acknowledged, or responded to them as required by facility policy and procedure. For example, one resident was prescribed Quetiapine for muscle weakness, which the pharmacist noted was not an appropriate diagnosis, and requested clarification and documentation of specific behaviors justifying the use of the antipsychotic. The pharmacist also recommended monitoring for side effects and specific behaviors for other medications, such as Buspar and Duloxetine, and requested that orders be updated to include monitoring for signs and symptoms of bleeding and thromboembolism for residents on anticoagulants like Rivaroxaban and Eliquis. In each case, the facility did not ensure that the physician reviewed or acted on these recommendations. Interviews with facility staff, including the DON and a corporate RN, confirmed that the physician had not signed or responded to the pharmacist's recommendations, and in some cases, the facility could not locate the recommendations or any response from the physician or DON. This deficiency was identified for all five residents reviewed, indicating a systemic failure to follow established procedures for pharmacist recommendations and physician review.