Failure to Ensure Proper Drug Regimen Review and Physician Response
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews (MRRs) by the consultant pharmacist were properly conducted, documented, and acted upon for multiple residents. For one resident with diagnoses including schizoaffective disorder and Parkinson’s disease, the medical record and MDS lacked documentation that a gradual dose reduction (GDR) for antipsychotic medication was attempted or that the physician documented a contraindication. The facility was unable to provide evidence of physician responses to the consultant pharmacist’s recommendations for GDR, and several months of MMRs were missing. Interviews revealed that nursing staff did not address the MMRs, and administrative staff expected the director of nursing to ensure physician review and retention of these records. Another resident with heart failure and atrial fibrillation had orders for as-needed diuretic medication that lacked administration parameters. The consultant pharmacist did not identify or report this irregularity, and the facility could not provide evidence of notification or clarification. Additionally, the consultant pharmacist requested clarification for the indication of an antidepressant, but the facility was unable to provide MMRs for several months. Nursing staff acknowledged that orders should have administration instructions and that unclear orders should be clarified, but did not address the MMRs as required. Further deficiencies included a resident with end-stage renal disease who had an order for Voltaren gel without dosing instructions, which was not identified or reported by the consultant pharmacist. Another resident receiving antidepressant medication did not have evidence of monitoring for continued use as recommended by the consultant pharmacist. Lastly, a resident prescribed lorazepam as needed for anxiety lacked documentation that the consultant pharmacist’s recommendation for a 14-day stop date was acknowledged or acted upon. Staff interviews confirmed a lack of awareness regarding the need for monitoring and stop dates, and administrative staff stated that the director of nursing was responsible for ensuring pharmacy reviews were completed.