Failure to Review and Document Pharmacist Recommendations for Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that pharmacist recommendations from monthly drug regimen reviews were reviewed and acted upon in a timely manner, and that documentation of these recommendations and physician responses was maintained in the medical record. For one resident with hemiplegia, hemiparesis, dysphagia, and anxiety disorder, the pharmacist made repeated recommendations over several months regarding multiple medication orders lacking associated medical diagnoses, particularly for psychotropic medications. There was no documentation that the physician reviewed or was informed of these recommendations until two months after the initial recommendation. For another resident with dementia, bipolar disorder, anxiety disorder, and adjustment disorder, the pharmacist's reports for two separate months referenced irregularities, but the facility was unable to provide documentation of these reports or any follow-up. Additionally, the facility did not have an established policy for drug regimen reviews and was relying on the pharmacy consultant to provide one. The lack of timely review, documentation, and policy implementation contributed to the deficiency.