Failure to Reconcile Admission Medications and Address Pharmacy-Identified Irregularity
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate medication reconciliation and appropriate follow‑up to a pharmacist’s drug regimen review for a newly admitted resident. The resident had diagnoses including aftercare following joint replacement, type 2 diabetes, hypertension, and hyperlipidemia, and was discharged from the hospital after a right total hip replacement with a recommendation for Atorvastatin 10 mg nightly for hyperlipidemia. The hospital discharge summary did not list migraine headaches as a diagnosis. Upon admission, a physician’s order was entered for Atogepant 10 mg by mouth once daily for hyperlipidemia, even though Atogepant is a medication used to treat migraine headaches. The admission evaluation signed the day after admission stated that all active medication orders had been reviewed and were accurate based on the Inter‑Agency Referral Form/W‑10. During the initial pharmacy medication regimen review conducted shortly after admission, the pharmacist identified a concern that Atogepant had been ordered with an incorrect clinical indication of elevated lipids. However, review of interim physician orders and provider progress notes over the following days showed no documentation that this pharmacy concern was reviewed or addressed by an APRN or physician. Provider progress notes during this period documented a full medication list including Atogepant and indicated that medications had been reviewed in the EMR, but did not address the pharmacist’s identified irregularity. Interviews with the DON, the attending physician, and the pharmacist confirmed that nursing staff were responsible for entering and reconciling admission orders, that the physician relied on pharmacy to notify the facility of inappropriate medications, and that the pharmacist recognized Atogepant’s indication as migraine headaches and not hyperlipidemia. The facility’s own Medication Verification and Medication Regimen Review policies required complete review of admission medications and documentation by the attending physician of any identified irregularities and actions taken, which was not done in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.