Physician Failed to Document Response to Pharmacist's Medication Recommendation
Penalty
Summary
A deficiency was identified when the attending physician failed to act upon a pharmacist's recommendation regarding a resident's medication regimen. The facility's policy requires that the attending physician document in the medical record whether a pharmacist's recommendation has been reviewed and what action, if any, has been taken. If no change is made to the medication, the physician must provide a rationale for this decision in the resident's record. In this case, the consultant pharmacist recommended a gradual dose reduction for Sertraline 25mg, an antidepressant prescribed to a resident with depressive disorder and weakness. Despite the pharmacist's recommendation, there was no documentation from the attending physician in the resident's clinical record explaining the rationale for continuing Sertraline or for rejecting the dose reduction. The DON confirmed that the physician had been notified of the recommendation via fax but had not responded as of the survey date. This failure to document and address the pharmacist's recommendation was found during a review of clinical records and staff interviews.