Failure to Clarify Medication Order Location Following Pharmacist Review
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation during the monthly Medication Regimen Review (MRR) for a resident who was prescribed Diclofenac Gel for pain management. The pharmacist's review specifically requested clarification from the physician regarding the exact location where the Diclofenac Gel should be applied. Despite this recommendation, the order remained unclarified, and the location of application was not specified in the resident's medical record. The resident involved had significant medical conditions, including diabetes mellitus and contact dermatitis, and was severely cognitively impaired, requiring total assistance with personal hygiene. The lack of clarification on the medication order meant that licensed nurses did not have the necessary information to know where to apply the medication, which was important for effective pain management. The facility's policy required timely communication and documentation of such recommendations, but these procedures were not followed in this instance.