Failure to Address and Document Pharmacist-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that irregularities identified by the consultant pharmacist during the monthly drug regimen review (MRR) were addressed in a timely manner and consistently documented in the medical record for one resident. The pharmacist's written recommendations and communications, which included concerns about off-label medication use, opioid tapering, and clarification of medication orders, were either not responded to, responded to with insufficient detail, or not documented in the resident's medical record. The MRR binder was also found to be incomplete and not readily available, with missing lists of reviewed residents and incomplete written reports. The resident involved had diagnoses including psychosis and Down Syndrome and was prescribed multiple medications, such as Trazodone for insomnia and Aripiprazole. The pharmacist repeatedly noted the need for documentation of off-label use rationale for Trazodone, evaluation of opioid use, and clarification of other medication orders. Despite these repeated recommendations, there was a lack of clear response or documentation from nursing or the physician, and actions taken were either not specified or not recorded in the resident's chart. During an interview, the clinical manager acknowledged that the MRR reports and binder were not complete or readily accessible, and that the pharmacist's communications were not properly addressed or documented. Facility policy required timely review and response to pharmacist recommendations, as well as maintenance of complete records, but these procedures were not followed in this instance.