Failure to Implement Pharmacist Medication Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to implement licensed pharmacist recommendations from monthly medication regimen reviews for one of five residents reviewed for unnecessary medications. Facility policy titled "Medication Regimen Review (Monthly Report)," revised April 22, 2025, states that recommendations are to be acted upon and documented by facility staff and/or the prescriber. Resident 7 had diagnoses including bipolar II disorder and major depressive disorder, with physician orders for olanzapine (Zyprexa) at bedtime for behaviors/mood and pantoprazole (Protonix) once daily. In the December 2025 monthly medication review, the pharmacist recommended that Protonix be administered on an empty stomach 30–60 minutes before a meal. The physician signed this recommendation on January 6, 2026, but the resident’s order continued to schedule Protonix at 9:00 AM, after the facility’s breakfast meal service, indicating the recommendation was not implemented. In the January 2026 monthly medication review, the pharmacist recommended adding an appropriate diagnosis for Zyprexa. The physician signed this recommendation on February 9, 2026, specifying bipolar II disorder as the diagnosis; however, the physician’s orders for Zyprexa were not updated to reflect that it was prescribed for bipolar II disorder. During an interview on February 11, 2026, the Nursing Home Administrator and DON reported they had no additional information as to why the pharmacy recommendations were not implemented and stated it was the facility’s expectation that pharmacy recommendations be implemented. These findings were cited under 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services.
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