Failure to Address Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a recommendation made by the consulting pharmacist regarding a resident's medication regimen. Specifically, the pharmacist identified a discrepancy in the resident's orders, noting that the discharge summary listed a Lidocaine 4% patch, while the active order in the system was for Lidocaine 4% gel. The pharmacist's recommendation, dated 2/18/25, requested verification and correction to ensure the correct item was active for the resident. Despite this recommendation, the Director of Nursing confirmed that the issue was not addressed by the physician, and a subsequent review of the resident's orders showed that the Lidocaine 4% gel order remained active. The resident's name was also missing from the facility's list of residents reviewed with no recommendations for February 2025, indicating a lapse in the medication regimen review process for this individual.