F0756

E

Failure to Implement Consultant Pharmacist Medication Regimen Review Recommendations

Eureka, California Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to act upon and implement consultant pharmacist (CP) medication regimen review (MRR) recommendations in a timely manner for multiple residents. The CP completed an MRR covering 12/01/25 to 12/31/25 and documented specific recommendations for Residents 1, 3, 6, 14, 16, 17, 18, 19, 24, 57, 76, 83, and 85. These recommendations included clarifying administration times, adding hold parameters, specifying monitoring instructions, and documenting hazardous drug precautions. On review of the residents’ order summaries dated 1/29/26, the surveyors found that none of these recommendations had been implemented or communicated to the prescriber as required by facility policy.

For Resident 1, admitted with BPH, the CP recommended specifying that tamsulosin 0.4 mg be given 30 minutes after the same mealtime each day and that capsules be swallowed whole without crushing, chewing, or opening. Resident 3, admitted with hereditary spastic paraplegia and receiving docusate sodium 100 mg two capsules twice daily, had an MRR recommendation to update the order to include “hold for loose stool.” Resident 6 and Resident 24, both receiving finasteride 5 mg daily for BPH, had MRR recommendations noting that finasteride is a hazardous medication that cannot be crushed or opened without appropriate PPE, and that the orders should be updated to state “Hazardous Drug – Please use appropriate PPE.” These changes were not reflected in the active orders at the time of review.

Resident 14, with hypothyroidism and GERD, had orders for famotidine 20 mg and levothyroxine 88 mcg both given in the morning; the CP recommended changing the famotidine administration time to 9 a.m. so it would not be given at the same time as levothyroxine. Resident 16, with HTN and on lisinopril 20 mg at bedtime, had an MRR recommendation to add monitoring parameters to the order: “Hold if HR < 60 bpm or SBP < 100 mmHg.” Resident 17, admitted with constipation and receiving senna and PRN acetaminophen, had recommendations to add “hold for loose stool” to the senna order and “do not exceed 3 grams of acetaminophen in 24 hours from all sources” to the acetaminophen order. None of these recommended order clarifications or monitoring parameters had been added.

Resident 18, admitted with gout and receiving allopurinol 300 mg daily, had an MRR recommendation to change the order to include “give with food/meals” and to add this to the directions to ensure compliance. Resident 19, with metabolic encephalopathy and multiple constipation medications (docusate sodium, polyethylene glycol, and senna), had recommendations to add “hold for loose stool” to the laxative orders and to specify for polyethylene glycol “stir in four to eight ounces juice or other liquids.” Resident 57, with type 2 diabetes and on melatonin 3 mg at bedtime, had a recommendation to change the indication to “for Circadian Rhythm Regulation.” Residents 76, 83, and 85, all receiving docusate and/or senna for constipation, had MRR recommendations to add “hold for loose stool” to their laxative orders. These changes were not present in the residents’ active orders on 1/29/26.

During interviews, the DON confirmed that none of the CP’s recommendations from the 12/26/25 MRR had been implemented or provided to the physician, and acknowledged that the CP recommendations should be followed because they prevented potential medication errors from happening. The CP stated that he performed the MRR on 12/26/25 and that his expectation was that recommendations would be reviewed within two weeks and, if not addressed, escalated by the DON. The Administrator stated that the last MRR review signed by the physician was dated 11/21/25 and that her expectation was that the 12/26/25 CP recommendations should have been followed and implemented in a timely manner. Review of facility policies showed that findings and recommendations from the CP are to be reported to the DON, attending physician, medical director, and Administrator, and that recommendations are to be communicated and acted upon in a timely fashion, with responses expected prior to the next MRR. These policy requirements were not met in relation to the December MRR recommendations for the identified residents.

The facility’s written policies titled “Medication Regimen Review” and “Documentation and communication of consultant pharmacist recommendations” specified that resident-specific irregularities and clinically significant risks associated with medications must be documented in the active record and reported to the DON, medical director, and prescriber as appropriate. The policies further required that the facility establish a system to ensure CP observations and recommendations are communicated to those with authority to implement them and that recommendations are acted upon and documented in an appropriate and timely fashion, enabling a response before the next MRR. Despite these policies, the survey findings showed that the December CP recommendations for the 13 residents were neither implemented nor documented as acted upon by facility staff or prescribers by the time of the survey on 1/29/26.