Delayed Response to Pharmacy Recommendations for Drug Regimen Review
Penalty
Summary
The facility failed to act in a timely manner on pharmacy recommendations identified during monthly drug regimen reviews for two residents. For one resident with diagnoses including gout, irregular heartbeat, and depression, the pharmacist recommended a uric acid level test and a reduction in Eliquis dosage. The uric acid test was not completed until 49 days after the recommendation, and the Eliquis dosage was not reviewed until 104 days after the initial recommendation. Staff interviews confirmed uncertainty regarding the required timeframe for processing pharmacy recommendations and acknowledged the delay in addressing these recommendations. For another resident with a history of stroke and receiving antipsychotic medications, the pharmacist recommended completion of an Abnormal Involuntary Movement Scale (AIMS) assessment, as it was not found in the medical record. Despite repeated recommendations in consecutive months, the AIMS assessment was not completed until 51 days after the initial recommendation. Staff confirmed that pharmacy recommendations should be addressed promptly and acknowledged that these recommendations were not processed in a timely manner for this resident.