Failure to Communicate Pharmacy Lab Recommendations to Physician
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician was made aware of a pharmacy consultant's recommendation for laboratory monitoring for a resident with multiple diagnoses, including atrial fibrillation, dementia, hypertension, heart failure, and diabetes. The resident was receiving several medications, including metformin, which carries a boxed warning for lactic acidosis risk, especially in those with kidney disease. The pharmacy consultant recommended checking A1c and BMP labs every six months, but this recommendation was not communicated to or acknowledged by the physician, and no corresponding order was found in the resident's electronic health record. The facility's process required pharmacy recommendations to be placed in a book for physician review, with the expectation that the physician would accept or deny the recommendation and sign the form. However, due to a backlog following a change in the Director of Nursing, this process was not completed, resulting in the physician not being informed of the pharmacy's recommendation and the necessary lab orders not being placed. The facility's policy directed that medication review recommendations be provided to relevant staff, but this was not followed in this instance.