Failure to Ensure Timely Follow-Up of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up of pharmacy recommendations for a resident with multiple diagnoses, including Parkinson's disease, dementia, atherosclerotic heart disease, bradycardia, coronary artery disease, chronic diastolic heart failure, and hyperlipidemia. The resident was prescribed Aspirin for coronary artery disease, and during a monthly medication regimen review, the pharmacist recommended evaluating the continued use of Aspirin in light of current cardiovascular disease prevention guidelines, suggesting possible discontinuation. The DON selected to continue Aspirin and noted the medical director was notified, but the prescriber response section was left blank, and only the DON's signature was present on the form. Subsequent documentation showed that the pharmacist followed up on the recommendation, but the recommendation remained pending without a final response from the physician. The physician's acknowledgment to discontinue Aspirin was eventually documented, but the form lacked a date, and the discontinuation order was not finalized until several days after the follow-up request. The facility's policy required all medication regimen review findings and actions to be documented by the attending physician in the resident's medical record, which was not done in this case.