Failure to Timely Implement Pharmacist Recommendations for Residents with ESRD
Penalty
Summary
The facility failed to implement and address licensed pharmacist recommendations in a timely manner for two residents with end stage renal disease (ESRD). For one resident, the pharmacist recommended discontinuing a multivitamin containing Vitamin A and E, which are not advised for individuals with ESRD, and switching to Nephrocaps. The physician agreed with this recommendation, but the order to discontinue the multivitamin and initiate Nephrocaps was not transcribed or implemented until several months later, resulting in the resident continuing to receive the inappropriate multivitamin for an extended period. For another resident, the pharmacist recommended evaluating the use of Acetaminophen-Codeine, a medication advised to be avoided in dialysis patients, and suggested considering an alternative pain management option. The medication regimen review (MRR) was not addressed by the provider, and the resident continued to receive Acetaminophen-Codeine as ordered. The MRRs for this resident were not reviewed or acted upon until much later due to a breakdown in communication, as the MRRs were sent to a supervisor who was on leave and not seen by facility staff until after the deficiency was identified. Facility policy required that prescribers act upon drug regimen review recommendations within 7-14 days and document their response. In both cases, these requirements were not met, resulting in prolonged administration of medications that were not recommended for residents with ESRD. The failure to timely implement pharmacist recommendations and ensure proper documentation led to the identified deficiencies.