F0756

D

Failure to Ensure Physician Follow-Up on Consultant Pharmacist Medication Review Recommendations

Fort Scott, Kansas Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that consultant pharmacist (CP) recommendations from monthly medication regimen reviews (MMR) were reviewed and addressed by the attending physicians, as required by facility policy. For one resident with hypothyroidism, the CP’s MMR dated 09/24/25 identified that the resident was receiving medications requiring routine lab work and specifically requested the physician to indicate which labs, including thyroid-stimulating hormone (TSH), should be ordered. Although the MMR was stamped as faxed, the electronic medical record contained no evidence of any physician follow-up or response to this recommendation. Review of the resident’s record from January 2025 through February 2026 showed no TSH lab had been completed during that period, despite the resident having an active order for levothyroxine for hypothyroidism.

The resident with hypothyroidism had an annual MDS showing intact cognition and was largely independent in activities of daily living, with a care plan stating that the pharmacist reviewed medications monthly and as needed, and that staff were to monitor labs and diagnostic tests as ordered by the physician. The facility’s Medication Monitoring Medication Regimen Review and Reporting policy required that recommendations be acted upon within 30 calendar days or per facility-specific protocols, and that physicians either accept or reject recommendations and document their rationale in the medical record. However, the administrative nurse reported that she could not locate any physician follow-up to the 09/24/25 MMR for this resident and acknowledged that the facility had been experiencing a lack of physician response to MMRs.

For a second resident receiving multiple psychotropic medications, including risperidone, alprazolam, and citalopram, the consultant pharmacist conducted an MRR on 07/03/25 and documented that the resident was taking risperidone 0.5 mg three times daily along with other psychotropics, and suggested the physician consider a dose reduction. The facility was unable to provide any copy of the provider or facility’s response to this recommendation. The care plan for this resident documented long-standing use of psychotropic medications for anxiety, wandering, exit-seeking, tearfulness, and a history of behaviors, and indicated that staff were to monitor effectiveness and side effects and consult with the pharmacist and physician to adjust dosages when clinically appropriate. The consultant pharmacist later reported that he did not receive a response to the gradual dose reduction request and observed that the physician had instead increased the risperidone dose from 0.5 mg to 1 mg, after which he did not repeat the request in subsequent MRRs. The facility’s policy again required that physician interventions be documented, including acceptance or rejection of recommendations and the rationale, but no such documentation was found for this resident.

Across both residents, surveyors identified that the facility did not ensure that CP recommendations were acted upon and documented by the physicians within the time frames and processes outlined in the facility’s own Medication Monitoring Medication Regimen Review and Reporting policy. Administrative nursing staff acknowledged that physician responses to pharmacy recommendations were missing and that the facility did not receive the expected follow-up to the pharmacist’s MRRs. This lack of documented physician review and action on the CP’s recommendations for necessary lab monitoring and psychotropic dose reduction constituted the cited deficiency.