Failure to Follow Up on Pharmacist's Anticoagulant Recommendation
Penalty
Summary
The facility failed to acknowledge and/or act on the consultant pharmacist's recommendation regarding the use of an anticoagulant medication for a resident with a history of stroke, hypertension, chronic kidney disease, and moderate cognitive impairment. The pharmacist had identified that the resident was receiving Xarelto, which is listed in the 2019 Beers Criteria as having an increased risk of serious bleeding in adults over 75 years when used long-term. The pharmacist recommended considering discontinuation or replacement of Xarelto with Eliquis and sent this recommendation to the physician for follow-up. Despite this recommendation, there was no evidence in the clinical record that the facility obtained a response from the physician or followed up on the pharmacist's recommendation for over 42 days. The administrative nurse confirmed that the lack of follow-up was an oversight and the facility did not have a policy in place to address follow-up on consultant pharmacist recommendations. This inaction resulted in the resident continuing to receive the medication without documented physician review or response to the identified irregularity.