Failure to Address Pharmacy Recommendations in Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that pharmacy recommendations made during monthly drug regimen reviews were reviewed and addressed by the physician in a timely manner for five sampled residents. According to the facility's policy, a licensed pharmacist is required to review each resident's drug regimen monthly and report any irregularities to the attending physician, DON, and Medical Director, with the expectation that these reports are acted upon and documented in the physician's progress notes. However, clinical record reviews revealed that for five residents, pharmacy recommendations made over several months were not addressed by the physician, and there was no evidence of follow-up or documentation in the residents' medical records. Specifically, recommendations for medication changes or concerns were made by the pharmacist for each of the five residents on multiple occasions, but there was no documentation that these recommendations were reviewed or acted upon by the physician. The DON confirmed during an interview that there was no documentation to show that the pharmacy recommendations were addressed in a timely manner. This deficiency was cited under federal and state regulations governing drug regimen review and nursing services.