Failure to Follow Pharmacy Consultant Recommendations for Medication Regimen Review
Penalty
Summary
Surveyors identified that the facility failed to follow pharmacy consultant recommendations for two residents regarding medication regimen reviews. For one resident with diagnoses including diabetes, congestive heart failure, paranoid schizophrenia, and hypertension, pharmacy consultant recommendations were made over several months to clarify and update medication orders for potassium chloride, glucagon, loperamide, and Voltaren gel. Despite these recommendations being communicated to the facility and relevant staff, the orders were not updated in accordance with the pharmacist's guidance. The facility's policy required nursing and/or medical staff to review and act upon these recommendations, with the Unit Manager responsible for tracking physician responses, but documentation showed that recommendations were not consistently addressed or properly recorded in the electronic medical record. For another resident with diagnoses including diabetes, liver and colon cancer, and chronic kidney disease, the pharmacy consultant recommended clarifying pain medication orders to specify indications for mild and severe pain, and to distinguish when to use oxycodone versus acetaminophen. Despite these recommendations, the physician's orders for oxycodone did not include the required pain level parameters at the time of the survey. The deficiency was confirmed through review of the medical record and interviews with facility staff, who acknowledged that the recommendations had not been implemented prior to the surveyor's inquiry. The surveyors found that the facility's process for handling pharmacy consultant recommendations was inconsistent, with recommendations not always being acted upon or documented as required by facility policy. Interviews with staff revealed a lack of clear procedure for tracking and following up on pharmacy consultant recommendations, and documentation in the electronic medical record was incomplete. This resulted in medication orders not being updated to reflect the consultant pharmacist's recommendations for two residents.