Failure to Ensure Timely Physician Review of Pharmacist Recommendations
Penalty
Summary
Facility staff failed to ensure that a resident's attending physician evaluated the resident's total program of care, specifically by not providing documented evidence that the physician reviewed and acted upon pharmacist recommendations for a period of four months. The facility's Medication Regimen Review policy requires that the pharmacist report any irregularities to the attending physician, who must address these recommendations in a timely manner, no later than their next routine visit. However, for four consecutive months, there was no documentation that the physician reviewed the consultant pharmacist's medication regimen review (MRR) reports or addressed the identified irregularities for the resident. The resident in question was admitted with multiple diagnoses, including chronic pain, schizophrenia, anxiety disorder, and anoxic brain injury, and was prescribed several medications, such as antipsychotics, pain relievers, and narcotics. The consultant pharmacist's MRRs repeatedly identified issues requiring physician clarification, such as the need for specific pain scale parameters for PRN opioid orders and clarification of antipsychotic indications. Despite these recommendations being documented in the pharmacy progress notes for four consecutive months, there was no evidence in the medical record that the attending physician reviewed or acted upon them during that time frame. It was noted during staff interviews that the resident's primary doctor, who was also the medical director, left abruptly without notice, and another physician assumed care. However, the MRRs for the months in question remained unreviewed and unaddressed until a later date, resulting in a failure to ensure the physician's oversight of the resident's medication management and overall care program as required by facility policy.