Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding medication regimen reviews were considered and acted upon for four out of five sampled residents. According to the facility's policy, a licensed pharmacist is required to review each resident's medication regimen monthly and report any irregularities, which must then be addressed in a timely manner. However, multiple instances were identified where pharmacy recommendations were either not communicated to the physician or not acted upon, resulting in repeated recommendations and lack of documented follow-up. For one resident with dementia and behavioral disturbances, pharmacy recommendations for a gradual dose reduction (GDR) of psychotropic medications were repeatedly made over several months without evidence of action or discussion by the interdisciplinary team. Another resident with chronic heart conditions had pharmacy recommendations for periodic potassium assessments that were not followed up or documented in the clinical record. A third resident with depression and PTSD had multiple pharmacy recommendations to simplify opioid orders and initiate GDRs for psychotropic medications, but there was no physician response or evidence that these recommendations were sent to the physician. Lastly, a resident admitted for surgical aftercare had several pharmacy recommendations regarding pain and PRN medication orders that were not implemented, with facility staff acknowledging that recommendations were not sent to providers during a period when the regular pharmacist was on leave. Interviews with facility staff confirmed that pharmacy recommendations were not consistently communicated to physicians or addressed as required by policy. The lack of timely response and follow-up on pharmacist recommendations placed residents at risk for unnecessary medications and unaddressed medication-related issues.