Failure to Document Physician Response to Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that physician documentation was completed in response to pharmacist-identified medication regimen irregularities for two residents. For one resident with multiple diagnoses including diabetes, anemia, hypotension, quadriplegia, and seizure disorder, the pharmacist recommended evaluating and potentially discontinuing a zinc supplement due to possible adverse effects. This recommendation was made on three separate occasions, but there was no evidence that a physician reviewed, signed, or dated the recommendation, nor was there documentation of any action taken regarding the zinc supplement. For another resident with seizure disorder, anxiety, and depression, the pharmacist recommended obtaining a Valproic acid level to monitor Depakote therapy, as no such lab result was present in the clinical record. Although the physician signed and agreed with the pharmacist's recommendation, there was no documentation that the lab was ordered or completed. These findings indicate that the facility did not follow its policy requiring physician review and documentation of actions taken in response to pharmacist recommendations.