A resident with glaucoma, dementia, and bipolar disorder had orders for multiple eye drops, and the Consultant Pharmacist repeatedly recommended separating the drops by at least 5 minutes during administration. The record did not show that the provider reviewed or responded to the recommendation in a timely manner, and the DON stated that a two-month delay in implementing pharmacist recommendations would be considered a delay in care.
A resident with COPD, depression, and opioid dependence had monthly MRR recommendations that were not communicated and addressed in a timely manner. The consultant pharmacist repeatedly flagged two PRN albuterol orders, Paxil dosing above the recommended daily dose, and the need for a PRN Narcan order, but the related pharmacy reports were missing from the chart and the provider response was incomplete.
A resident with complex autoimmune conditions was prescribed Methotrexate weekly, but due to a transcription error, received the medication daily. The dispensing pharmacist overrode a DUR alert without verifying the order, and the pharmacy consultant failed to identify the excessive dosing during review. The resident developed acute toxicity, resulting in hospitalization for pancytopenia and related complications.
The facility did not ensure that monthly consultant pharmacist recommendations were addressed and maintained in the medical records for two residents, including recommendations related to medication reassessment, lab monitoring, and pain medication sequencing. Nursing staff and the DON reported lapses in the process, especially during a pharmacy transition, resulting in unaddressed recommendations and missing documentation.
The facility did not ensure that monthly medication regimen reviews were properly communicated to physicians and addressed in a timely manner for two residents. For one resident with severe cognitive impairment, a pharmacy recommendation was not documented or provided to the physician. For another resident, monthly reviews were not documented for several months, and a pharmacy recommendation regarding inhaler use was not addressed for two months, with documentation missing from the medical record.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its own irregularity reporting guidelines as outlined in policy and procedure.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its own irregularity reporting guidelines as outlined in policy and procedure.
A resident with hypotension and dysphagia did not have pharmacy consultant recommendations regarding as-needed cough syrup and menthol lozenges addressed or documented in a timely manner. Recommendations made over two consecutive months were not communicated to the physician or acted upon until more than two months later, and the related reports were missing from the medical record.
Two residents with ESRD did not have pharmacist recommendations addressed in a timely manner. One continued to receive a multivitamin containing Vitamin A and E, which was not recommended, for several months after the pharmacist and physician agreed it should be discontinued. Another resident continued to receive Acetaminophen-Codeine, which should be avoided in dialysis patients, because the medication review was not promptly addressed due to communication lapses.
A resident with impaired kidney function and recent falls continued to receive a higher dose of gabapentin for several months, despite the pharmacist’s recommendations and agreement from the NP and physician to reduce the dose. The facility did not implement the medication changes as directed, and staff interviews confirmed that pharmacy recommendations were not promptly addressed.
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