Failure to Implement Pharmacist Medication Recommendation
Penalty
Summary
A deficiency occurred when the facility failed to fully implement a pharmacist's medication recommendation for a resident with multiple complex diagnoses, including encephalopathy, type II diabetes mellitus, history of liver transplant, sepsis, atrial fibrillation, and acute kidney failure. The pharmacist had reviewed the resident's medication regimen and recommended changing the route of administration for Procrit from intramuscular to subcutaneous and to hold the medication if the resident's hemoglobin was 10 or more. While the route of administration was updated in the physician's orders, the instruction to hold Procrit for hemoglobin of 10 or more was not added. The Director of Nursing (DON) acknowledged responsibility for ensuring pharmacy recommendations were addressed and confirmed that the recommendation regarding the hemoglobin threshold was missed. The facility's policy required that all pharmacist recommendations be followed up on within 30 days to ensure appropriate action. This oversight resulted in the resident's medication orders not fully reflecting the pharmacist's recommendations as required by facility policy.