Failure to Address and Document Pharmacist Recommendations in Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that irregularities identified by the Consultant Pharmacist during monthly drug regimen reviews were addressed and that documentation of these reviews was maintained and readily available. Multiple residents receiving antipsychotic and other high-risk medications did not have required assessments, such as the Abnormal Involuntary Movement Scale (AIMS), completed at the recommended intervals. For example, one resident on antipsychotic medication had only one AIMS assessment on file, despite repeated pharmacist recommendations for ongoing assessments, and there was no evidence that these recommendations were acknowledged or acted upon by staff. Additionally, recommendations regarding medication administration timing, such as separating psyllium from other medications to avoid absorption issues, were not communicated or implemented, and staff were unaware of these recommendations. The report also documents that medication regimen review reports and pharmacy recommendations were not consistently maintained or accessible in the facility. In several cases, the facility was unable to provide copies of pharmacy recommendations for extended periods, and staff interviews revealed confusion about who was responsible for receiving, addressing, and storing these recommendations. The Director of Nursing (DON), Nurse Practitioner (NP), and Administrator each described different processes and responsibilities, leading to a lack of clarity and follow-through. In some instances, recommendations to hold medications based on clinical parameters, such as blood pressure, were not followed, and there was no documentation that these issues were addressed by nursing or medical staff. Residents affected by these deficiencies included individuals with complex medical histories, such as those with bipolar disorder, anxiety, depression, hypertension, and heart failure, who were prescribed multiple medications requiring careful monitoring. The lack of proper documentation, communication, and follow-up on pharmacist recommendations resulted in repeated medication administration errors and missed assessments. Staff interviews confirmed that recommendations were often not received, acknowledged, or acted upon, and there was no established system for ensuring that pharmacy recommendations were addressed and retained in the residents' records.