Failure to Address and Document Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist were addressed in a timely manner and maintained as part of the permanent medical record for two residents. For one resident with diagnoses including type 2 diabetes mellitus, hypertension, and major depressive disorder, the consultant pharmacist's recommendations from April and May were not found in the medical record and were not acted upon. These recommendations included reassessing the necessity of Meclizine, an anticholinergic medication, and ordering an A1c lab every three months for diabetes management. The medical record did not show that the physician addressed these recommendations, and the last A1c lab was collected several months prior to the review. For another resident with a history of artificial knee joint, morbid obesity, anxiety, and depression, the consultant pharmacist's recommendations from April and May were also missing from the medical record and were not addressed. The recommendations included sequencing multiple as-needed pain medications and ordering specific labs for monitoring antipsychotic and other medication use. The medical record did not indicate that these recommendations were reviewed, implemented, or declined by the provider. Interviews with nursing staff and the DON revealed that there was confusion and a lack of clear process regarding the handling of pharmacy recommendations, particularly during a transition to a new pharmacy provider. Unit Managers were responsible for ensuring recommendations were reviewed and completed, but lapses occurred, and recommendations were not always received or documented. The DON acknowledged that pharmacy recommendations should have been addressed and maintained in the medical record, but this was not consistently done.