Failure to Implement Pharmacist-Recommended Change in Hydroxyzine Dosing
Penalty
Summary
The deficiency involves the facility’s failure to act on a Consultant Pharmacist’s monthly medication regimen review and update a resident’s hydroxyzine order in the electronic medical record after the physician had signed to change the order. Resident #8, admitted with diagnoses including pruritus, had a physician’s order dated 7/10/23 for hydroxyzine 25 mg three times a day for pruritus. The Consultant Pharmacist’s Medication Regimen Review dated 1/12/26 documented that on 12/12/25 the physician signed the pharmacy consult report to change the hydroxyzine to 25 mg every morning and midday and discontinue the three-times-daily dosing. However, this new order was not entered into the electronic medical record. Review of the Medication Administration Record from 12/12/25 through 1/18/26 showed that Resident #8 continued to receive hydroxyzine 25 mg three times a day, as evidenced by nursing signatures, indicating the original order remained in effect despite the physician-approved change. The Director of Nursing reported that the Consultant Pharmacist emailed monthly medication regimen reviews and described a process in which physician recommendations from these reviews were to be placed in a physician’s notebook and, once signed, entered into the electronic record. The DON stated she was new to the facility in December 2025 and did not promptly address the December pharmacy reports, resulting in a delay in implementing the reduced hydroxyzine dosing until the Consultant Pharmacist notified her the following month that the frequency had not been changed. The Clinical Compliance Administrator confirmed that medication regimen reviews were expected to be addressed as soon as the DON received them.
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