Failure to Address Pharmacy Recommendations for Medication Use
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were properly addressed by the attending physician for two residents reviewed for unnecessary medications. For one resident, the consultant pharmacist identified that daily supplements of Vitamin D and oyster shell calcium may be unnecessary and requested the physician to consider discontinuation, but there was no documented physician response. Additionally, the pharmacist requested an updated diagnosis to justify the combined use of Prozac and Zyprexa for treatment-resistant major depressive disorder. Although the physician indicated that orders were updated, the active orders continued to list previous diagnoses, and there was no evidence that the orders were revised to reflect the pharmacist's recommendation. For another resident, the consultant pharmacist noted that Risperidone was prescribed for dementia, which is not an approved diagnosis for this medication, and requested clarification. The physician later indicated the medication was for depression, but there was no documentation that the facility addressed or followed up on the physician's response to the pharmacist's recommendation. These findings were confirmed through clinical record review and staff interviews, indicating a failure to ensure that pharmacy recommendations were appropriately addressed and documented.