Failure to Complete Pharmacy Recommendations Following Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that pharmacy recommendations resulting from monthly drug regimen reviews were completed for three of five sampled residents. According to facility policy, a licensed pharmacist is required to conduct a medication regimen review for each resident, with any recommendations provided to the primary care provider and Director of Nursing (DON) for review and action prior to the next review. However, record reviews revealed that pharmacy recommendations for multiple residents were not addressed in a timely manner, as required by policy. For one resident with diagnoses including anxiety, mild dementia with mood disturbance, and depression, pharmacy notes indicated repeated requests for reassessment of PRN Lorazepam over several months, with no evidence that facility staff followed up on these recommendations. Another resident, who had moderate cognitive impairment and was receiving several medications including an antidepressant, had repeated pharmacy recommendations for a gradual dose reduction (GDR) of Escitalopram that were not addressed for nine months. A third resident with dementia, chronic kidney disease, depression, and hypertension also had pharmacy recommendations for GDR of psychotropic medications that were not acted upon for three months. Interviews with the DON confirmed that the expectation was for pharmacy recommendations to be completed within one week of receipt, but this was not done for the residents in question. The lack of timely follow-up on pharmacy recommendations was confirmed through both record review and staff interviews, indicating a failure to comply with facility policy and regulatory requirements regarding medication regimen review and follow-up.