Failure to Act on Consultant Pharmacist PRN Psychotropic Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that consultant pharmacist recommendations from monthly medication regimen reviews were acted upon and that physician responses were documented in the medical records for two residents receiving PRN psychotropic medications. For one resident with an anxiety disorder and a PEG tube, the physician ordered Lorazepam Intensol 2 mg/ml, 1 ml via PEG every 2 hours PRN for anxiety. This PRN psychotropic and controlled substance order, initiated in early May, remained active through mid-December without a stop date, while the medication was administered two to three times weekly. Monthly pharmacy consultation reports from July through December repeatedly recommended that the physician address the PRN Lorazepam order due to the missing stop date, but there was no evidence in the consultation reports or the resident’s EMR that any physician reviewed, accepted, declined, or otherwise responded to these recommendations. A second resident with major depression and an anxiety disorder had a physician order for Lorazepam 1 mg by mouth every 8 hours PRN for anxiety and agitation, also a psychotropic and controlled substance. This PRN order remained active from mid-October through mid-December without a stop date, and the medication was administered one to two times weekly. A pharmacy consultation report in November recommended that the physician address the PRN Lorazepam order due to the lack of a stop date, but there was no documentation that the physician reviewed or responded to this recommendation. A subsequent pharmacy medication regimen review note in December documented no irregularities or recommendations, despite the ongoing PRN Lorazepam order without a stop date. Interviews revealed that the consultant pharmacist completed monthly medication regimen reviews for all residents and, when regulatory concerns were identified, emailed recommendation reports to the DON and Administrator. The established process was for the DON to handle nursing-related recommendations, forward physician-related recommendations to the appropriate physician, and ensure that the physician reviewed, accepted, or declined them with documented rationale. The consultant pharmacist stated that PRN psychotropic medications required a stop date and physician review before renewal, and that he had sent the relevant reports to facility leadership. However, due to turnover among DONs and Administrators, the process was disrupted, and the pharmacist did not receive responses to his recommendations before the DON left. The interim DON and current Medical Director both reported being unfamiliar with the process and unaware of the unaddressed pharmacy recommendations, and a former Medical Director stated he had not received any pharmacy recommendation reports and confirmed that the consultation reports for the affected residents were not reviewed or signed by a physician.
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