Failure to Ensure Timely Physician Review of Pharmacist Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that a physician reviewed and documented actions taken in response to monthly pharmacist recommendations regarding a resident's drug regimen. Over a period of four months, pharmacy consultation reports repeatedly identified that a resident was receiving an antipsychotic medication without adequate documentation of diagnosis or indication for use in the electronic medical record (EMR). Each monthly report recommended updating the EMR with a specific diagnosis, a list of symptoms or target behaviors, evidence that other causes and medications had been considered, documentation of individualized non-pharmacological interventions, and orders for ongoing monitoring. Despite these repeated recommendations, there was no evidence in the resident's record that the physician had reviewed the pharmacist's findings or documented any actions taken to address the identified irregularities. The pharmacy consultation reports for January, February, March, and April all lacked a physician's signature or any indication of review or follow-up. The resident in question had moderate cognitive impairment, mild depression, and was receiving both antidepressant and antipsychotic medications, with care plans in place to monitor for adverse reactions and behavioral symptoms. Interviews with the Director of Nursing (DON) revealed that although she received the pharmacist's recommendations each month, she had not distributed them to the physicians for the past four months due to being behind on other tasks. As a result, the required physician review and documentation of actions taken in response to the pharmacist's recommendations did not occur, leading to the deficiency.