Failure to Timely Implement Pharmacy Recommendation for PRN Narcan
Penalty
Summary
The facility failed to follow through on a pharmacy recommendation regarding medication safety for a resident with multiple diagnoses, including chronic pain syndrome, anxiety, and a tracheostomy. The resident was prescribed both an opioid (Oxycodone) and a benzodiazepine (Clonazepam), a combination that increases the risk of life-threatening overdose. On 04/08/25, the pharmacy recommended that PRN Narcan (a narcotic reversal medication) be available for this resident, and this recommendation was documented as accepted with a verbal order from the physician. Despite the acceptance of the pharmacy's recommendation, a review of physician orders showed that PRN Narcan was not actually ordered for the resident until 06/04/25, nearly two months later. The Director of Nursing confirmed that the order for PRN Narcan was not placed in a timely manner and was only completed after pharmacy recommendations were specifically requested. This delay in implementing the pharmacy's recommendation constituted a failure to act promptly on identified drug regimen irregularities as required by regulation.
Plan Of Correction
F0756 - Drug Regimen Review The resident #135 during the survey had their medication regimen reviewed by the Nurse Practitioner on 6/4/24 in house who addressed the recommendation. PRN order implemented on 6/4/2024. A retrospective audit of all residents' monthly drug regimen reviews over the past 60 days was conducted on 6/25/25 by the consultant pharmacist. Any missed or undocumented irregularities were addressed, and physicians were notified to ensure appropriate follow-up and documentation on 7/2/25. Nursing leadership will be educated by RNC on ensuring timely follow-up to pharmacy recommendations by 6/18/2025. The DON or designee will audit 100% of pharmacist recommendations weekly for 4 weeks then monthly for 2 months. All findings will be reported to the QA committee for review, which meets monthly and as needed. Compliance date: July 10, 2025
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