Failure to Address Pharmacy Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding residents' medication regimens were addressed in a timely manner, as required by policy and regulatory guidelines. For one resident with dementia and mood disturbances, there was no documentation of a monthly medication review by a pharmacist for a specific month, and pharmacy recommendations regarding the use of Seroquel and monitoring for orthostatic blood pressure changes were not communicated to the psychiatric APRN for over six weeks. The Director of Nursing acknowledged that the pharmacy recommendation was not placed in the APRN communication book, resulting in a significant delay in provider review and response. Additionally, the recommended orthostatic blood pressure monitoring was not implemented as directed by the pharmacy. For another resident with anxiety disorder and dementia, pharmacy recommendations regarding the continued use and justification of PRN Ativan were not addressed. The Director of Nursing did not discuss the recommendations with hospice, who was involved in the resident's care, and there was no recordkeeping of pharmacy recommendations after they were received by the facility. The psychiatric APRN was not made aware of the need to re-evaluate the PRN Ativan until prompted by surveyor inquiry, and the facility's process for ensuring timely review and response to pharmacy recommendations was not followed. Interviews with facility staff, including the Director of Nursing, medical director, and APRNs, revealed inconsistent expectations and practices regarding the handling and documentation of pharmacy recommendations. The facility was unable to provide a policy for pharmacy recommendations and monthly reviews when requested. These failures resulted in pharmacy recommendations not being addressed within the expected timeframes and a lack of documentation and follow-through on medication regimen reviews for the residents involved.