Failure to Ensure Timely Physician Response to Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were completed by a consultant pharmacist and that recommendations were addressed by the attending physician or prescriber in a timely manner for two of five residents reviewed. Facility policy did not specify a required timeframe for physician response to pharmacy recommendations. For one resident with diagnoses including major depressive disorder, anxiety, and intellectual disabilities, pharmacy recommendations to discontinue as-needed ondansetron and to add amlodipine were documented, but there was no evidence of physician response or action taken on these recommendations. The resident's orders continued to include ondansetron and did not include amlodipine, and the facility was unable to provide proof of physician response. For another resident with major depressive disorder and anxiety, a pharmacy recommendation for a gradual dose reduction of mirtazapine was made during a medication regimen review, but the physician did not address this recommendation until more than two months later, after being prompted for a response. Staff interviews confirmed the expectation that physicians should review and respond to medication regimen reviews in a timely manner, but this did not occur for the residents in question.