Failure to Act on Pharmacist's Recommendation for Medication Monitoring
Penalty
Summary
The facility failed to ensure that a consultant pharmacist's recommendation to consider ordering valproic acid and ammonia levels for a resident was acknowledged and acted upon. The resident in question had diagnoses including congestive heart failure, anemia, and psychosis, and was prescribed Depakote Delayed Release for mood disorder. The consultant pharmacist documented a recommendation in the Medication Regimen Review for the physician to consider ordering these laboratory tests to monitor the therapeutic blood level of the medication. However, the facility did not inform the resident's physician of this recommendation, and no orders for the tests were placed. The Director of Nursing confirmed that the facility's policy requires pharmacy consultant recommendations to be addressed within 14 days and that the purpose of the recommended tests was to ensure the medication was safe to administer. The facility's policy also states that recommendations should be acted upon and documented by staff or the prescriber, with the physician either accepting and acting on the suggestion or providing an explanation for disagreement. In this case, there was no documentation of action or physician response regarding the pharmacist's recommendation.