Failure to Document Rationale for Declining Pharmacist Recommendations and Delayed Nursing Response
Penalty
Summary
The facility failed to ensure that physicians or prescribers documented the rationale for declining pharmacist recommendations for two residents reviewed for unnecessary medications. In both cases, the consultant pharmacist made specific recommendations regarding medication adjustments or monitoring, such as attempting a gradual dose reduction of psychotropic medications and initiating additional pain management or laboratory monitoring. The prescribers declined these recommendations but did not provide any patient-specific rationale or explanation in the medical record, as required by facility policy and procedure. Interviews with the Director of Nursing and the Advanced Practice Registered Nurse confirmed that explanations were not consistently provided, and the expectation for documentation was not always met. Additionally, the facility did not ensure timely nursing response to a pharmacist's recommendation for another resident. The pharmacist recommended updating an inhaled corticosteroid order to include instructions for rinsing the mouth after use to reduce the risk of thrush. The recommendation was not addressed promptly, and the order remained unchanged without the additional instructions. The Director of Nursing acknowledged that recommendations are typically addressed within 48-72 hours but could not explain the delay in this instance. Review of facility policy confirmed that prescribers are expected to document their rationale for rejecting pharmacist recommendations and that the nursing department should act upon such recommendations in a timely manner. The records reviewed showed that these procedures were not consistently followed, resulting in incomplete documentation and delayed implementation of pharmacist recommendations.