Failure to Implement Pharmacist Medication Review Recommendations and Provider Orders
Penalty
Summary
The facility failed to implement provider orders based on the Consultant Pharmacist’s (CP) monthly medication review (MRR) and did not ensure a medication review system that prevented duplication or omissions for a resident with vascular dementia and major depressive disorder. The resident’s medical record showed a history of moderately to severely impaired cognition, use of a wheelchair, and dependence on staff for daily activities. The resident was prescribed venlafaxine for depression, and the care plan included monitoring for side effects and routine evaluation for possible dose reduction. During the CP’s MRR, a recommendation was made to reduce the venlafaxine dose in accordance with federal guidelines. The physician responded in writing to decrease the dose, and a prescription was sent to the pharmacy. However, the electronic health record (EHR) lacked evidence that staff acknowledged or acted on this order promptly, and there was no progress note documenting the medication change. Later, conflicting documentation appeared, with the physician indicating disagreement with the dose reduction and referencing previous unsuccessful attempts at gradual dose reduction (GDR). The resident’s medication administration record eventually reflected a dose change, but the process was marked by confusion and lack of clear communication among staff and providers. Interviews with facility staff revealed a lack of understanding regarding the MRR process and the presence of two separate MRR forms from different providers for the same medication issue. The facility’s drug regimen review policy did not specify nursing responsibilities related to the MRR, contributing to the breakdown in communication and implementation of provider orders. This deficient practice placed the resident at risk of receiving unnecessary medications due to the failure to properly coordinate and document medication regimen changes.