Failure to Address Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations for a resident were reviewed and addressed by the attending physician, as required by facility policy. The resident in question had multiple psychiatric diagnoses, including dementia with agitation, depression, and schizophrenia, and was receiving antidepressant medication as part of his care plan. The consultant pharmacist conducted a monthly medication regimen review and recommended discontinuing the resident's mirtazapine due to the resident's weight and BMI, suggesting an alternative antidepressant. This recommendation was documented and a note was written to the physician. However, there was no evidence in the clinical record that the attending physician had reviewed or acknowledged the pharmacist's recommendation. The physician stated during interview that he typically reviews pharmacy recommendations every one or two weeks and responds by marking agree or disagree on the form, which is then uploaded to the medical record. In this case, the physician was unsure if the recommendation had been addressed and could not confirm whether he had seen it. The psychiatric nurse practitioner also did not document any review or consideration of the pharmacist's recommendation in her progress notes. Facility policy requires that within twenty-four hours of the medication regimen review, the consultant pharmacist provides a written report to the attending physician, who must document in the medical record that the irregularity was reviewed and what action, if any, was taken. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that the process involves placing pharmacy recommendations in the provider's folder for review and response, but upon review, they could not locate any documentation that the recommendation for this resident had been addressed. This resulted in a failure to ensure that medication irregularities identified by the pharmacist were reviewed and acted upon by the physician.