Failure to Act on Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to act on a recommendation from the consultant pharmacist regarding a resident's medication regimen review. Specifically, the pharmacist identified that a hospitalist had recommended the continuation of allopurinol 100 mg daily for a resident, but there was no corresponding physician order for this medication. The pharmacist's recommendation was documented in the medication regimen review, but there was no evidence that the attending physician was notified or that the recommendation was evaluated and addressed. Interviews with the Regional Director of Clinical Services and the Director of Nursing confirmed that there was no documentation showing the physician had been made aware of the pharmacist's recommendation or had reviewed it. The facility's policy required that such recommendations be communicated to the prescriber and addressed within a specified timeframe, but this process was not followed for the resident in question.