Failure to Follow Consultant Pharmacist Recommendations and Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly drug regimen review (MRR) and that recommendations were appropriately followed for two residents. For one resident with diagnoses including gastroesophageal reflux disease (GERD) and chronic pain, the consultant pharmacist identified issues with medication forms and dosing frequencies during the MRR. However, there was no evidence that nursing staff reviewed or acted upon these recommendations, as indicated by the absence of signatures or documentation on the MRR and confirmed by interviews with nursing staff and the Director of Nursing (DON). For another resident with a history of atrial fibrillation and pulmonary embolism who was receiving anticoagulant therapy (rivaroxaban), the facility did not order baseline or periodic laboratory work to monitor kidney function and blood levels, despite this being an intervention listed in the resident's care plan. The MRR reports for this resident did not address the lack of laboratory monitoring, and both the DON and the consultant pharmacist confirmed that this oversight occurred. The consultant pharmacist acknowledged that baseline and periodic blood work should have been recommended but was not identified during the monthly review. Facility policies required that consultant pharmacist findings be communicated to the DON or designee and that recommendations be acted upon and documented within 72 hours. Additionally, the facility's anticoagulation protocol specified that appropriate lab testing should be ordered to monitor anticoagulant therapy. These policies were not followed, resulting in missed medication clarifications and lack of necessary laboratory monitoring for residents receiving high-risk medications.