Failure to Document and Communicate Pharmacy Medication Review Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacist's medication regimen review recommendation was properly documented and communicated for one resident. The resident in question was admitted with multiple diagnoses, including dementia, bipolar disorder, and depression, and was assessed as being severely cognitively impaired. On a specific date, the pharmacist indicated that a comment or recommendation had been made regarding the resident's medication regimen, as noted in the progress note. However, a review of the resident's electronic medical record did not reveal any documentation of what the pharmacist's recommendation or comment was, nor any evidence that the physician had reviewed or acted upon it. Interviews with the DON confirmed that the expected documentation, which should have been scanned into the resident's EMR, could not be located. Further attempts to obtain the report from an outside company providing physician services were unsuccessful, as they also did not have a copy of the relevant pharmacy report. The facility's policy requires that any irregularities identified by the pharmacist be reported to the attending physician, medical director, and DON, and that the physician document their review and any actions taken in the resident's medical record. In this case, there was no documentation to confirm that these steps were followed.