Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist consultant recommendations were acted upon for all five residents reviewed for unnecessary medications. Each resident's monthly pharmacy reconciliation included specific recommendations from the consulting pharmacist, such as requests for laboratory workups, order clarifications, clinical rationales for continued medication use, and suggestions for medication adjustments or discontinuations. Despite these recommendations, there was no evidence in the medical records that the facility responded to or updated the physicians regarding the pharmacist's findings for any of the residents involved. For example, one resident with multiple diagnoses including hypertension, dementia, and depression had recommendations for a laboratory workup for an antipsychotic and clarification of an antidepressant order, but no follow-up was documented. Another resident with heart failure, renal insufficiency, and anxiety had repeated requests from the pharmacist for clinical rationales for continued use of certain medications, which were not addressed. Additional residents had recommendations related to medication schedule changes, laboratory monitoring, and dose reductions, none of which were documented as having been communicated to the prescribing providers. Interviews with the consulting pharmacist and the DON confirmed that the facility was expected to resolve medication review recommendations prior to the next monthly pharmacist visit, but this was not done. The facility's own policy required staff to act upon all pharmacist recommendations according to established procedures, yet records showed a consistent lack of follow-through, leaving the recommendations unaddressed for multiple residents over several months.