Failure to Receive and Act on Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure that drug regimen review recommendations from the pharmacy consultant were received and acted upon for one resident. Specifically, the pharmacy consultant sent recommendations regarding medication adjustments for a newly admitted resident, but these recommendations were not received by the Director of Nursing (DON) due to an email delivery failure. As a result, the recommendations were not reviewed or implemented in a timely manner, contrary to the facility's policy requiring monthly pharmacist review and appropriate communication of medication issues to prescribers and facility leadership. The resident involved was an elderly female with multiple complex diagnoses, including traumatic brain injury, fractures, diabetes, cognitive impairment, and other chronic conditions. Her medication regimen included pain management and several other medications. The pharmacist's recommendations included changes to the administration of metformin, consideration of a temporary hold on Lipitor, initiation of calcium/vitamin D supplementation, and a stop order for PRN Norco. These recommendations were not available to the care team or acted upon until the issue was discovered and the recommendations were resent. Interviews with facility leadership confirmed that the process for ensuring receipt and implementation of pharmacy recommendations was not followed as outlined in facility policy. The DON was unaware of who was responsible for verifying receipt of pharmacy communications, and the recommendations for the resident were missing from the pharmacy binder for the relevant month. This lapse resulted in a delay in reviewing and potentially implementing important medication changes for the resident.