Failure to Address Pharmacist-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that drug regimen review (MRR) irregularities identified by the consultant pharmacist were addressed by the attending physician for three residents. For one resident with lower back pain and a spinal compression fracture, a pharmacy recommendation to specify the application area for a lidocaine patch was not acted upon. In another case, a resident with Alzheimer's disease had pharmacy recommendations regarding the administration of Miralax and clarification of vitamin D therapy, which were not addressed despite repeated notes from the consultant pharmacist. A third resident with dementia, vitamin D deficiency, and folate deficiency anemia had recommendations to add appropriate diagnoses for several medications, but these were also not addressed. Record review and staff interviews confirmed that there was no evidence the MRR irregularity recommendations were reviewed or acted upon by the physician for these residents, and the Director of Nursing Services was unable to provide documentation of follow-up. The facility's policy requires monitoring of consultant pharmacy services and timely response to identified irregularities, but this was not followed in these cases until the issues were identified by surveyors.