Delayed Response to Pharmacy Recommendations for Medication Regimen Reviews
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for two residents reviewed for unnecessary medications. For one resident with multiple diagnoses including anxiety and depression, the pharmacist recommended a trial discontinuation of Xanax while titrating buspirone upward. Although the prescriber indicated agreement, there was no identifiable signature or date, and the recommendation was not addressed in a timely manner, with the medication only discontinued several months later. Nurses' notes did not mention the pharmacy recommendations during this period, and facility leadership confirmed the delay in addressing the pharmacist's input. For another resident with epilepsy and a history of encephalitis, the pharmacist recommended adjusting the administration schedule of Trazodone and monitoring for adverse effects, but the physician did not respond to the recommendation, and the medication was eventually discontinued by a hospital physician. Additionally, the pharmacist recommended clarifying the duration and monitoring requirements for Enoxaparin, but the physician did not respond until approximately two months later. Facility policy required monthly medication regimen reviews and timely physician responses to pharmacist recommendations, which were not followed in these cases.