Failure to Document Physician Review of Pharmacy-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician documented in the medical record that identified medication regimen irregularities had been reviewed and what, if any, actions were taken to address them for one resident. Specifically, pharmacy recommendations regarding the resident's medication regimen in August and September were communicated to the facility, but there was no documentation in the resident's progress notes indicating that a provider had reviewed or responded to these recommendations. The pharmacist reported sending communications about the resident's medications and noted a lack of direct response from the provider, with the process defaulting to continuation of the current regimen in the absence of a response. The ADON stated that her process was to forward pharmacy reviews to providers and await a response, but if no response was received, she did not follow up and the medication regimen continued as ordered. The physician overseeing care was unaware of the unanswered pharmacy recommendations and expected immediate responses to such communications. Review of facility policy indicated that the pharmacist, in collaboration with the facility and medical director, is responsible for developing and revising procedures for pharmaceutical services, but the required documentation and follow-up were not completed in this case. The resident involved had a history of intentional self-harm and chronic pain, was taking opioid medication, and had intact cognition.