Delayed Medical Provider Review of Pharmacist Medication Regimen Recommendation
Penalty
Summary
Facility staff failed to ensure that a medication regimen review (MRR) completed by a licensed pharmacist was reported to and acted upon by the medical provider in a timely manner for one resident. The pharmacist completed the MRR and made recommendations regarding the resident's antipsychotic medication, specifically suggesting an evaluation and possible dose reduction of Olanzapine. However, the recommendation report was not found in the resident's clinical record, and there was no evidence that the medical provider had acknowledged or reviewed the recommendation until three months after the MRR was completed. The resident involved had multiple complex diagnoses, including hypertension, Alzheimer's disease with early onset, chronic respiratory failure, cerebrovascular disease, diabetes, epilepsy, depression, anxiety, dementia, chronic kidney disease, and schizoaffective disorder. The resident was also noted to have severe cognitive impairment. Facility policy required timely physician response to pharmacist recommendations, and documentation of review in the medical record, but these steps were not followed in this instance.