Failure to Act on Pharmacist's Medication Regimen Review Recommendation
Penalty
Summary
The facility failed to act upon a consultant pharmacist's medication regimen review (MRR) recommendation for a resident who was receiving Enoxaparin Sodium Injection (Lovenox) for deep vein thrombosis prophylaxis. The pharmacist's MRR specifically recommended that a duration of therapy be provided for the use of Lovenox. However, there was no documentation that the attending physician was notified of this recommendation, as confirmed by both a Licensed Vocational Nurse and the Director of Nursing during interviews and record reviews. The resident involved had a medical history including osteomyelitis, diabetes mellitus, and chronic obstructive pulmonary disease, and required varying levels of assistance with activities of daily living. The facility's policy and procedure required that the consultant pharmacist's findings and recommendations be reported to the physician and documented accordingly, but this process was not followed in this instance. As a result, the pharmacist's recommendation regarding the medication regimen was not communicated or acted upon.