Failure to Timely Address Consultant Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRR) conducted by the consultant pharmacist were communicated to the physician and addressed in a timely manner for one resident. Specifically, a recommendation made in October 2024 by the pharmacy consultant to evaluate the continued need for Oxycontin and MS Contin was not reviewed or responded to by the provider, as indicated by the absence of documentation in the medical record and a blank physician response section. Additionally, recommendations made in February 2025 to reassess the need for Protonix and to review the use of as-needed Oxycodone were not acted upon until two months after the recommendations were received, as shown by the delayed physician signatures and orders. The resident involved had a history of osteomyelitis of the left tibia/fibula and was receiving multiple medications, including opioids and a proton pump inhibitor. The facility's policies required that all consultant pharmacist recommendations be communicated to and addressed by the provider within 30 days, with follow-up if no response was received. Interviews with the consultant pharmacist and the DON confirmed that the recommendations were either not addressed or were addressed late, contrary to facility policy.