Failure to Address Consultant Pharmacist’s Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician reviewed and either implemented or documented a rationale for not following a consultant pharmacist’s recommendations for a resident’s medication regimen. The resident had essential hypertension and end stage renal disease requiring dialysis and was receiving multiple antihypertensive medications, including amlodipine, clonidine, and carvedilol, as well as midodrine for cramping related to dialysis. A New Admission Review form dated 11/18/25 documented that the pharmacist recommended evaluation of the concurrent use of medications for both hypertension and hypotension and suggested possibly holding the morning doses of antihypertensives on dialysis days. The form was signed by the unit manager but did not contain a provider signature. Record review showed no documentation in the resident’s medical record that the provider had reviewed the pharmacist’s recommendations or provided a clinical rationale for not following them. The resident’s orders for antihypertensives and midodrine had not been changed since the pharmacist’s recommendation. During interviews, the unit manager confirmed the pharmacist’s recommendation and acknowledged the absence of the provider’s signature and any changes to the medication orders, and stated she could not determine if the provider had reviewed the recommendation. The DON confirmed that providers were expected to review all pharmacist recommendations, sign the recommendation forms, and document a clinical rationale if they did not agree with the recommendations, which had not occurred in this case.
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