Failure to Follow Up on Pharmacy Medication Regimen Review
Penalty
Summary
The facility failed to ensure proper follow-up on a monthly pharmacy medication regimen review for one resident. The resident, who had diagnoses including type 2 diabetes, unspecified protein-calorie malnutrition, schizoaffective disorder, major depressive disorder, and anxiety, was cognitively intact according to the most recent assessment. The pharmacy review for this resident dated 1/31/25 included a recommendation to consider discontinuing loratadine-D due to its potential to worsen hypertension, and to consider an alternative antihistamine if needed. However, the pharmacy consultation report did not have a documented response from the physician, nor did it include signatures from the physician or the Director of Nursing (DON). Further review revealed that the recommendation was not followed up on, as the DON reported only receiving the blank pharmacy recommendation after the fact. The lack of documented follow-up and absence of required signatures indicated that the facility did not ensure the pharmacy's recommendation was addressed in a timely manner, as required by policy and procedure.