Failure to Implement Physician-Approved Pharmacy Recommendation for Medication Reduction
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the administration of Omeprazole, a proton pump inhibitor (PPI). The resident, who had multiple diagnoses including atherosclerotic heart disease, diabetes mellitus, dementia, osteoporosis, dysphagia, major depressive disorder, hypertension, and gout, had been receiving Omeprazole 40 mg daily since admission. Pharmacy recommendations dated 12/04/2025 advised decreasing the Omeprazole dose to 20 mg daily due to risks associated with long-term use, and the physician agreed to this recommendation on 12/10/2025. However, review of the medication administration record showed that the resident continued to receive the higher 40 mg dose, indicating the physician-approved pharmacy recommendation was not implemented. Interviews with nursing staff and administration revealed that the process for updating medication orders based on pharmacy recommendations involved the DON and ADON, who were responsible for reviewing, processing, and entering new orders once approved by the physician. Despite this established process, the recommended change was not made, and staff were unable to explain why the order was not updated. The facility's policy on handling unnecessary medications or pharmacy recommendations was requested but not provided during the survey. The administrator acknowledged responsibility for ensuring that pharmacy recommendations, once approved by the physician, are implemented and monitored by nursing administration.