Failure to Ensure Physician Response to Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRRs) conducted by the pharmacist were addressed by the attending physician and properly documented in the clinical records for two residents. For one resident, the pharmacist made multiple requests for clarification of a diclofenac order and recommended a Gradual Dose Reduction (GDR) for quetiapine, but there was no documentation of physician response or rationale for declining these recommendations in the electronic medical record (EMR). The orders remained unamended, and the physician's section of the MRR forms was left blank. For another resident, the pharmacist recommended obtaining a lipid panel and A1c due to daily use of rosuvastatin and quetiapine, but there was no evidence in the EMR or laboratory results that these tests were performed, nor was there documentation of the physician's reasoning for not following the recommendation. The Director of Nursing confirmed that the facility did not have a system in place to ensure physician responses to pharmacist recommendations were documented, and the facility's policy required providers to review and address all pharmacist recommendations.