Failure to Communicate Pharmacist Lab Recommendations to Physician
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a consultant pharmacist’s medication regimen review (MRR) recommendation was communicated to the physician for one resident. During an unannounced visit, surveyors reviewed the record of Resident A, who had diabetes mellitus and severe cognitive impairment with a BIMS score of 3. Resident A’s orders included Lantus 25 units at bedtime and Humalog insulin before meals and at bedtime per sliding scale, with a prior HgbA1C order and result of 10.5%. The Medication Administration Record from early January through early February showed blood glucose levels above 200 mg/dl with Humalog administered per sliding scale. The resident’s care plan documented hyperglycemia and poor glycemic control related to Type 2 diabetes mellitus, evidenced by the elevated HgbA1C and use of sliding scale insulin, with instructions to reassess nutritional status and glycemic control routinely. A review of the consultant pharmacist’s MRR dated December 22, 2025, showed a recommendation to clarify with the physician the need for HgbA1C and Vitamin D 25 OH lab tests. Further review of the resident’s record revealed no documented evidence that this recommendation was implemented or referred to the physician after it was made. In an interview, the DON confirmed that the pharmacy consultant’s recommendation for lab tests for this resident was not communicated to the physician and acknowledged that it should have been discussed. The facility’s Medication Regimen Review policy stated that the consultant pharmacist is to review each resident’s medication regimen monthly, identify and report medication-related problems and irregularities, and provide written reports to attending physicians, the DON, and the Medical Director, with copies and physician responses maintained in the permanent medical record. This process was not followed for Resident A’s recommended lab monitoring.
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