Failure to Implement Physician-Approved Pharmacy Recommendations
Penalty
Summary
The facility failed to implement pharmacy recommendations that were approved by the facility physician for a resident with diagnoses including dementia, COPD, and cerebral infarction. The contracted pharmacy conducted a new admission review and recommended changes to the resident's medication regimen, including adjusting the Lidocaine patch order, discontinuing Oxybutynin, and switching from Xarelto to Eliquis. The physician reviewed and approved these recommendations, ordering the changes as suggested by the pharmacy. Despite the physician's approval, the facility did not implement the medication changes for the resident. Medical record review confirmed that the approved pharmacy recommendations were not carried out, and interviews with staff, including the MDS nurse and DON, verified there was no documentation of the orders being implemented. Additionally, the hospice RN reported that hospice was not contacted regarding the approved medication changes, and if they had been informed, they would have coordinated with the hospice physician and approval department.