Lack of Physician Documentation in Response to Pharmacist's Drug Regimen Review
Penalty
Summary
The facility failed to ensure that drug regimen review irregularities documented by the pharmacist received a documented review and response from the attending physician or medical director for one resident. Specifically, a resident with diagnoses including anxiety disorder, delusional disorder, and bipolar disorder was prescribed Seroquel for bipolar mood disorder. During an April psychopharmacology meeting, the pharmacist recommended changing the diagnosis associated with the Seroquel order from anxiety/delusions to bipolar disorder, and this recommendation was documented in the pharmacy review note. However, the facility was unable to provide any provider notes indicating that the attending physician or medical director reviewed and responded to the pharmacist's recommendation. The medical director confirmed in an interview that he did not document his review or actions regarding the medication diagnosis change, stating only that he changed the order. This lack of documentation failed to meet the facility's requirement for a documented physician response to pharmacist-identified drug regimen review irregularities.