Failure to Address and Implement Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication regimen review (MRR) irregularities and pharmacist recommendations were received and addressed by the physician for two residents. For one resident with multiple complex diagnoses, including cerebral palsy, epilepsy, and scoliosis, the pharmacist made several recommendations over a period of months, such as changes to Vitamin D dosing, lab monitoring for seizure medication, and administration timing for warfarin. Documentation of these recommendations and their review or implementation by the physician was missing or incomplete in the resident's medical record. In one instance, although the physician accepted a pharmacist's recommendation to change Vitamin D dosing, the change was not implemented for over ten months. Additionally, there was no evidence that the physician was notified in a timely manner of a critical recommendation regarding warfarin administration, and documentation of physician review for other recommendations was not found. For another resident with a diagnosis of GERD, the pharmacist recommended tapering and discontinuing omeprazole and ordering a basic metabolic panel (BMP) during routine MRRs. Although the physician accepted the recommendation to taper and discontinue omeprazole, the medication continued to be administered as before, and the change was not implemented. For the BMP recommendation, the physician accepted the recommendation, but there was no documentation in the electronic medical record (EMR) that the lab was completed as directed or that the physician reviewed a previous lab result to determine if it was sufficient. Interviews with facility staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), confirmed the lack of documentation and failure to implement or address the pharmacist's recommendations. In some cases, signed consultation reports were found outside of the residents' medical records, and in other cases, the facility was unable to provide any evidence that the recommendations were reviewed or acted upon by the physician. The deficiencies were identified through record review and staff interviews, and as of the survey exit, the facility had not provided additional information to demonstrate compliance.