Failure to Act on Pharmacy Recommendation for Supplement Dosage
Penalty
Summary
Facility staff failed to act upon a pharmacist's recommendation to specify the dosage for a prescribed supplement, Cyanocobalamin, for one resident. The pharmacist's recommendation, dated 02/19/25, was not addressed by nursing staff, and the pharmacy review form remained unsigned. The process described by the DON involved receiving recommendations via email, printing and forwarding them to physicians, and then checking for new orders before filing the signed form, but this process was not followed in this instance. The supplement order lacked a specified strength, and a dose was not added until over two months later. Additionally, an LPN signed off that the supplement was administered twice on the same day, and the DON was unable to explain why the recommendation was not addressed.