Failure to Timely Address Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen review (MRR) recommendations made by the pharmacy consultant were communicated to the physician and addressed in a timely manner for one resident. Specifically, recommendations made in August and September 2024 to evaluate the continued use of as-needed Geri-tussin (cough syrup) and menthol lozenge were not reviewed or responded to by the provider until November 4, 2024, which was 80 days after the initial recommendation. The pharmacy consultant's reports from August and September were also not found in the resident's medical record, indicating a lapse in documentation and follow-through with established policy requirements. The resident involved had a history of hypotension and dysphagia and had been prescribed Geri-tussin syrup and menthol lozenges on an as-needed basis, both of which were discontinued on November 4, 2024. Facility policy required that pharmacy consultant recommendations be acted upon within relevant time frames and documented in the resident's medical record. During an interview, the DON confirmed that the recommendations were not addressed in a timely manner and that the relevant reports could not be located in the resident's record.