Failure to Implement Agreed Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication regimen review recommendations were implemented in accordance with the physician or nurse practitioner’s response for one resident. The consulting pharmacist made recommendations on two occasions to adjust the resident’s gabapentin dosage due to impaired kidney function and recent falls, with the physician and nurse practitioner both agreeing to the recommendations. However, the medical record did not show that these recommendations were acted upon, and the resident continued to receive the higher dose of gabapentin for several months following the recommendations. Interviews with the DON, nurse practitioner, and medical director confirmed that pharmacy recommendations, once agreed upon, should have been implemented by nursing staff. The DON acknowledged that pharmacy recommendations were behind in being addressed, and the nurse practitioner confirmed that the resident’s medication order had not been changed as recommended. The medical director also stated that agreed-upon pharmacy recommendations should result in a new order being placed in the medical record.