Physician Review of Pharmacist Medication Recommendations Not Documented
Penalty
Summary
The facility failed to ensure that a physician reviewed and acted upon a pharmacist's recommendation following a monthly Medication Regimen Review (MRR) for a resident with atrial fibrillation and heart failure. The resident was prescribed amiodarone and carvedilol, both of which can affect heart rate, and the pharmacist recommended monitoring for signs of bradycardia due to the combined effects of these medications. However, there was no documentation indicating that the physician had reviewed or responded to the pharmacist's recommendation for the month of May. Interviews and record reviews revealed that the MRR was typically kept in the DON's office, and staff would inform the physician of any recommendations if requested. In this instance, the responsible RN was not asked to review the MRR, and the DON had resigned, resulting in a lack of follow-up. Facility policy required that recommendations from the pharmacist be acted upon and documented by staff or the prescriber, with the physician expected to accept, act upon, or reject the suggestion by the next visit. This process was not followed for the resident in question.