Physician Failed to Act on Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that the physician reviewed and acted upon irregularities identified by the consultant pharmacist for one resident who was reviewed for unnecessary medications. According to the facility's policy, recommendations and findings from the consultant pharmacist are to be documented and acted upon by the nursing care center and/or physician. However, medical record reviews revealed that for a resident with diagnoses including heart disease, schizoaffective disorder, chronic kidney disease, and delusional disorders, the physician did not sign or document a response to multiple consultant pharmacist recommendations regarding medication regimen adjustments. These recommendations included suggestions to decrease dosages of hydroxyzine and clonazepam over several months. Despite the consultant pharmacist's documented recommendations in monthly reports, there was no evidence in the medical record that the physician acknowledged or addressed these recommendations. The Director of Nursing confirmed during an interview that the physician was present in the facility at least monthly to review reports, but the consultant pharmacist's recommendations were not acted upon by the physician. This lack of documented physician response to identified medication irregularities constitutes a failure to follow facility policy and regulatory requirements.