Failure to Act on Pharmacy Recommendations for Medication Regimen
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding a resident's medication regimen were reviewed and acted upon as required. Specifically, a resident with diagnoses including non-Alzheimer's dementia, anxiety, and depression had a physician order for acetaminophen, but the order did not specify a maximal daily dose. The pharmacy made repeated recommendations over several months to update the order to include the maximum daily dose of 4000 mg, but these recommendations were not addressed or signed by the physician, despite being presented multiple times. The resident's care plan included regular evaluation of the drug regimen by the physician, and the facility's policy required that pharmacy recommendation forms be addressed and signed by the physician to make any medication changes. However, the physician failed to act on the pharmacy's recommendations, and the facility was unable to provide a policy on pharmacy recommendations when requested. This inaction resulted in the deficiency identified during the review of clinical records, facility policy, and staff interviews.