Failure to Implement Pharmacist's Medication Safety Recommendation
Penalty
Summary
The facility failed to act upon the Consultant Pharmacist's recommendation to add 'do not crush' instructions to a resident's Dulcolax delayed release (DR) medication order. The resident in question had diagnoses of major depressive disorder, Alzheimer's disease, and a history of cerebrovascular accident, with severely impaired cognition and significant assistance required for activities of daily living. The resident's care area assessment indicated a risk of adverse side effects from medications, and the care plan directed nursing staff to administer medications as ordered by the physician. However, the medication order for Dulcolax DR did not include 'do not crush' instructions, despite the pharmacist's recommendation documented in the monthly medication review. Review of the resident's medication administration record for the relevant month confirmed the absence of the 'do not crush' directive for Dulcolax. Interviews with administrative nursing staff revealed an expectation that pharmacy recommendations would be reviewed and acted upon within seven days, but this was not done in this case. The facility's policy required that drug regimen reviews be conducted monthly by a licensed pharmacist, with any identified irregularities reported to the attending physician, medical director, and director of nursing services for action. The failure to implement the pharmacist's recommendation resulted in a deficiency related to the management of the resident's medication regimen.