Delayed Response to Pharmacist Recommendations on Medication Orders
Penalty
Summary
The facility failed to act upon irregularities identified by the consulting pharmacist in a timely manner for four residents. According to the facility's policy, pharmacist recommendations must be implemented within seven days. For multiple residents, pharmacy reviews repeatedly noted issues such as missing order durations for PRN psychoactive medications, lack of documented rationale for continued use beyond 14 days, and missing indications for PRN pain medications. These recommendations were documented over several months but were not addressed within the required timeframe. Specifically, one resident with anxiety had pharmacy recommendations regarding the duration and documentation for Clonazepam orders that were not addressed for nearly three months. Another resident with pain management needs had repeated recommendations to clarify PRN pain medication orders for moderate pain, which were not acted upon over a four-month period. Additional residents with orders for Lorazepam, Doxazosin, Valproic Acid, and Alprazolam also had pharmacy-identified irregularities, such as missing order durations and diagnoses, that were not corrected until weeks or months after the initial recommendations. These delays in addressing pharmacist recommendations were confirmed through review of clinical records, pharmacy reviews, and facility policy.