Failure to Ensure Adequate Drug Regimen Review and Reporting by Consultant Pharmacist
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) performed adequate monthly drug regimen reviews and appropriately identified and reported medication irregularities to the Director of Nursing (DON) and the Medical Director. Specifically, the CP did not document or communicate the appropriate Centers for Medicare & Medicaid Services (CMS) indications for the use of antipsychotic medications for several residents, despite their ongoing use of these medications for behavioral and psychiatric symptoms. For multiple residents with dementia, major depressive disorder, and other behavioral disturbances, the CP's reviews lacked recommendations or documentation regarding the clinical justification for antipsychotic use, and there was no evidence that the required gradual dose reductions (GDR) or risk versus benefit rationales were consistently addressed or communicated to the physician or DON. Additionally, the CP failed to identify and report missed vital sign monitoring for residents receiving heart medications such as metoprolol, digoxin, and carvedilol. For two residents, medication administration records showed that blood pressure and pulse were not documented prior to the administration of these medications over multiple months, as required by physician orders and standard practice. The CP's monthly reviews did not include recommendations or notations regarding the absence of this critical monitoring, and there was no evidence that these omissions were brought to the attention of the nursing or medical staff. Interviews with administrative nursing staff revealed a lack of clarity and follow-through regarding the pharmacist's responsibilities and communication processes. Although pharmacy and therapeutics meetings were held monthly and the CP completed paper reviews, there was no system in place to ensure that the physician reviewed or signed off on the pharmacist's findings, nor was there a process to ensure that recommendations or concerns were addressed. Facility policy required the CP to communicate potential or actual medication-related problems to the responsible physician and DON, but this was not consistently done, resulting in missed opportunities to address medication safety and appropriateness.