Lack of Documentation for Physician's Rationale on Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a rationale was documented in response to a pharmacy recommendation for one resident. According to the facility's policy, the pharmacy consultant is required to review all resident charts monthly and suggest therapeutic changes as needed. If a physician or nurse practitioner declines a pharmacy recommendation, the policy requires that the reason for not accepting the recommendation be documented in the resident's progress notes. In this case, the clinical record review for a resident with diagnoses of Type 2 diabetes, heart disease, and hypertension showed that the consultant pharmacist recommended discontinuing sliding scale insulin (SSI) due to minimal use and current geriatric guidelines. The pharmacist requested that, if no changes were made, the physician should provide a comment. The physician disagreed with the pharmacist's recommendation but did not provide any rationale or comment in the resident's clinical record, as required by facility policy. This omission resulted in a lack of documentation explaining the physician's decision to continue the current diabetes management regimen. The deficiency was identified during a review of the resident's clinical record and the facility's pharmacy consultation policy.