Failure to Ensure Timely Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and addressed by a physician in a timely manner for four out of five sampled residents. According to facility policy, a licensed pharmacist is required to conduct a monthly drug regimen review for each resident 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 multiple residents with complex medical histories—including schizoaffective disorder, intermittent explosive disorder, major depressive disorder, anxiety, emphysema, a femur fracture, cerebral infarction, dementia, and dysphagia—pharmacist recommendations were made on several occasions but were not addressed or documented by the physician. Specifically, for one resident, pharmacist recommendations made in February and April were not addressed; for another, recommendations from January, February, and April were not acted upon; and for two additional residents, recommendations from March, January, and February were either not documented or not addressed by the physician. During an interview, the Administrator confirmed the lack of documentation regarding the pharmacy recommendations and their timely review or action by the physician.