F0756

D

Failure to Discontinue Medication After Accepted Pharmacy Recommendation

Buffalo, Wyoming Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to act on a pharmacy recommendation and corresponding physician order to discontinue an unnecessary medication for one resident. A monthly medication regimen review for December 2025 documented that the consulting pharmacy recommended discontinuing hydroxyzine 25 mg, ordered as needed for anxiety. The medical record showed that the physician accepted this recommendation and ordered the hydroxyzine to be discontinued. However, review of the physician orders revealed that the hydroxyzine order remained active and had not been discontinued. In an interview on 1/23/26 at 8:30 AM, the DON confirmed that the medication had not been discontinued. Review of the facility’s policy, “Interim Medication Regimen Review” (last updated 2018), showed that the physician/prescriber should accept and act upon recommendations contained within the monthly medication review, which did not occur in this case.

This failure to implement the accepted pharmacy recommendation and physician order for discontinuation of hydroxyzine for anxiety constituted noncompliance with the facility’s own policy and procedures for monthly drug regimen review and unnecessary medications.