Failure to Act on Pharmacist Recommendations and Identify Medication Irregularities
Penalty
Summary
The facility failed to ensure that pharmacist consultant recommendations were acted upon and that irregularities in monthly drug regimen reviews were properly identified and addressed for several residents. For one resident with multiple diagnoses including cancer, diabetes, and chronic pain, the consultant pharmacist made recommendations regarding a PRN order for Prochlorperazine, noting the need for a 14-day stop date or a switch to an alternative medication. These recommendations were documented in the consultant pharmacist's reports for two consecutive months, but there was no evidence in the medical record that the recommendations were implemented or that the provider was contacted for clarification. The medication remained on the resident's record without use, and the facility lacked a tracking system to ensure follow-up on pharmacist recommendations. For another resident with diagnoses including bipolar disorder and major depression, the medical record showed active orders for several medications, including statins and antipsychotics, but lacked evidence of pharmacy consultant recommendations for necessary laboratory monitoring. Interviews with nursing staff and the DON revealed that there was no facility policy or standing order for lab monitoring of these medications, and the consultant pharmacist did not identify or recommend lab monitoring during monthly reviews, relying instead on the provider to order labs. A third resident with Alzheimer's disease and anxiety had an active PRN order for lorazepam without a required 14-day stop date. The consultant pharmacist did not identify or recommend an end date for this medication during the monthly review, and the order remained in place without proper documentation or justification for continued use. The facility's policies and procedures were also found to be lacking, as they did not address requirements for lab monitoring, PRN psychotherapeutic medication use, or the necessary 14-day stop date and face-to-face provider evaluation for PRN psychotropic medications.