Failure to Ensure Timely Physician Review of Pharmacist Medication Regimen Recommendations
Penalty
Summary
Facility staff failed to ensure that a licensed pharmacist's monthly medication regimen review (MRR) recommendations and identified irregularities were reviewed and acted upon by the attending physician for one resident. The facility's policy requires that the pharmacist report any medication irregularities to the attending physician, Medical Director, and DON, and that these reports be addressed in a timely manner. For a resident with multiple complex diagnoses, including chronic pain, schizophrenia, anxiety disorder, and anoxic brain injury, the pharmacist documented several recommendations and requests for clarification regarding pain medication parameters and antipsychotic indications over a four-month period. Despite the pharmacist's repeated documentation of irregularities and recommendations in November, December, January, and February, there was no evidence in the resident's medical record that the attending physician reviewed or acted upon these reports during that time. The recommendations included clarifying PRN opioid pain medication orders with specific pain scale parameters and reviewing the indications for antipsychotic medications, as well as updating administration instructions for a lidocaine patch. These recommendations were not addressed until March, several months after they were initially made. Interviews with facility staff revealed that the delay was partly due to the abrupt departure of the resident's primary physician, who was also the Medical Director, and the subsequent transition to a new physician. However, there was no documentation or explanation for why the MRRs were not reviewed or acted upon during the four-month period, resulting in a failure to comply with facility policy and regulatory requirements for timely physician review of pharmacist-identified medication irregularities.