Failure to Act on Pharmacy Consultant Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure that physicians or advanced practice registered nurses (APRNs) acted upon pharmacy consultant recommendations in a timely manner for three residents reviewed for unnecessary medications. For one resident with multiple complex diagnoses, including diabetes, stroke, epilepsy, and gastrostomy, the pharmacy consultant made several recommendations over multiple months regarding medication management, such as adding stop dates for anticoagulants, switching medication forms for easier administration via feeding tube, and monitoring for side effects. Despite these recommendations, there was no documentation that the physician or APRN responded to or acted upon them within the expected timeframe, as required by facility policy. Interviews with facility staff confirmed that the process for following up on pharmacy recommendations was inconsistent, with forms not always being reviewed, signed, or returned by the responsible providers. Another resident with a history of stroke, diabetes, and heart failure was started on an antipsychotic medication, and the pharmacy consultant recommended baseline and ongoing monitoring for side effects, as well as laboratory testing for lipid profiles. The clinical record review revealed that these recommendations were not completed, and the forms were not signed or dated by the provider. Interviews with nursing and pharmacy staff confirmed that the recommendations were not reviewed or acted upon, and the required monitoring and laboratory tests were not documented in the resident's record. A third resident with bipolar disorder and hyperlipidemia was receiving an antipsychotic medication, and the pharmacy consultant recommended ordering a lipid profile and HbA1C due to the risk of diabetes and dyslipidemia. Although the prescriber agreed with the recommendations, only the HbA1C was completed, and there was no documentation that the lipid profile was ordered or completed. Facility staff interviews indicated that the process for ensuring completion of pharmacy recommendations was not consistently followed, resulting in missed or delayed actions on important medication management recommendations.