Failure to Respond to Pharmacy Recommendations for Medication Regimen Reviews
Penalty
Summary
A deficiency occurred when pharmacy recommendations were not followed or responded to by the physician, DON, or nursing staff for three of six sampled residents over periods extending up to ten months. For one resident with dementia, chronic kidney disease, and emphysema, the physician failed to respond to the pharmacist's recommendations regarding the use of Rexulti for agitation for five months. Another resident with a history of stroke, dementia, and nerve pain had a high-risk medication combination of gabapentin and an opioid, with the pharmacist requesting a risk-benefit analysis and effectiveness documentation, but the physician did not respond for ten months. A third resident with dementia and aggressive behaviors was prescribed Zyprexa, and the pharmacist's repeated recommendations for a gradual dose reduction and improved behavior documentation went unaddressed for four consecutive months. The facility's policy required that the consultant pharmacist review medication regimens and that the physician respond to recommendations, documenting the rationale for continuing medications if indicated. However, clinical record reviews showed a lack of physician or nursing staff response to the pharmacist's recommendations in the medical records for the residents involved. The pharmacist confirmed that reminders were given to the DON and nursing staff regarding the need for specific behavior documentation and consideration of dose reductions, but these recommendations remained unaddressed.