Failure to Act on Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's recommendations regarding a resident's medication regimen were acted upon and documented, as required by facility policy. Specifically, for one resident with a history of chronic ulcer, edema, and cellulitis, the pharmacist made recommendations on two separate occasions to address the administration of Tylenol (acetaminophen) for pain management. The recommendations noted that if a PRN (as needed) pain medication is ordered for any level of pain (mild, moderate, or severe), there must be PRN orders for all levels, or the PRN pain management is considered inadequate. Despite these recommendations, there was no evidence that the facility staff or prescriber acted upon or documented any changes or decisions regarding the pharmacist's suggestions in the resident's medical record for the period reviewed. Record reviews and staff interviews confirmed that the pharmacist's recommendations were not followed or documented in the progress notes, and the facility's protocol was cited as the reason for inaction. The resident's medication administration records for May, June, and July indicated ongoing orders for Tylenol for mild pain, but there was no documentation addressing pain management for other pain levels as recommended. The facility's policy required that pharmacist recommendations be acted upon and documented by staff or the prescriber, which did not occur in this instance.