Failure to Act on Pharmacist Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to ensure that recommendations from the consultant pharmacist's monthly Medication Regimen Review (MRR) were acted upon for three residents. For one resident prescribed Quetiapine, the pharmacy recommended an EKG to monitor for potential cardiac effects, but the EKG was not completed as ordered. Both the registered nurse and the assistant director of nursing confirmed that the EKG was missed and not documented in the resident's record, despite the pharmacy's recommendation and the facility's policy requiring such follow-up. Another resident was prescribed Seroquel for psychosis manifested by sudden anger outbursts. The consultant pharmacist recommended ensuring proper documentation for the use of Seroquel, including evidence that the symptoms were due to mania or psychosis, that non-drug interventions had been attempted, and that the behaviors presented a danger or significant distress. The pharmacist also recommended monitoring for orthostatic hypotension and obtaining specific lab tests. The facility did not ensure that these recommendations were followed, and the required documentation and monitoring were not completed in a timely manner. The resident's family member refused a gradual dose reduction, but the facility did not escalate the issue to the medical director as outlined in their policy. A third resident was receiving Klonopin for behavioral control without a documented progress note from the physician explaining why this long-acting benzodiazepine was the best choice. The consultant pharmacist requested updated documentation, but the physician's progress note did not address the rationale for continued use. The director of nursing confirmed that the required documentation was missing, and the resident could be receiving the medication without an appropriate indication. These failures were contrary to the facility's policies and procedures regarding psychotropic medication use and documentation.