Failure to Ensure Proper Pharmacist Irregularity Reporting and Physician Response
Penalty
Summary
The facility failed to ensure that the consultant pharmacist reported medication regimen irregularities to the attending physician and Director of Nursing on a separate, written report, as required by policy. For one resident, the consultant pharmacist's recommendations regarding medication adjustments and laboratory monitoring were included in lists with other residents' information and directed to nursing staff, rather than being provided to the physician on a separate report. The recommendations included updating a Seroquel order and ensuring periodic labs for Cholestyramine, but these were not referred directly to the physician, nor was a separate report documented in the resident's medical record for several months. Additionally, when the consultant pharmacist did request a physician review of Hydroxyzine for a possible gradual dose reduction, the physician did not document a review and response until more than a month later. The only evidence of the pharmacist's review for that month was a report listing multiple residents, without a separate report for the physician. The Director of Nursing confirmed the absence of required separate reports in the resident's chart for the months in question, and that the physician's response to the pharmacist's recommendation was not timely documented.