Failure to Address Pharmacist Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to act on recommendations made by the pharmacist during monthly drug regimen reviews for a resident reviewed for unnecessary medication use. Specifically, the pharmacist identified that the resident had physician orders for two PRN pain medications, Tylenol and Tramadol, but the orders did not specify the pain scale rating to guide nursing staff on when to administer each medication. The pharmacist recommended that the physician clarify the orders to include the pain scale rating, but this recommendation was not addressed by the physician. Additionally, a subsequent pharmacist review noted that Tramadol PRN had not been used in the past 60 days and recommended discontinuing the medication to reduce unnecessary drug storage and associated risks. This recommendation was also not acted upon by the physician. Interviews with the DON confirmed that both pharmacist recommendations were not addressed, and there was no documentation or physician response to the pharmacist's reports in the resident's medical record.