Consultant Pharmacist Fails to Identify Drug Irregularities
Penalty
Summary
The consultant pharmacist at the facility failed to identify drug irregularities during monthly medication reviews for two residents. Resident 114, who was diagnosed with dementia with behavioral disturbances and major depressive disorder, was prescribed dual antidepressant therapy with Venlafaxine and Mirtazapine. Despite the presence of duplicate antidepressant therapy, the consultant pharmacist did not identify this irregularity or provide recommendations to assess the appropriateness of the therapy. Additionally, there was no documented clinical rationale justifying the prescribing of two antidepressants. Resident 130, diagnosed with dementia with severe agitation and depression, was prescribed Olanzapine, an antipsychotic, without documented justification for its use. The consultant pharmacist's new admission medication review failed to identify the lack of documented justification for the continued use of Olanzapine. Furthermore, the pharmacist identified a discrepancy in the dosing of Aricept, but the resident continued to receive the medication as prescribed without timely clarification or modification. The Director of Nursing confirmed that the consultant pharmacist failed to identify and address medication regimen irregularities for both residents. Additionally, Resident 130's attending physician did not timely act upon the pharmacist's recommendations and failed to provide a documented clinical rationale for the continued use of antipsychotic medication. These deficiencies were found to be in violation of specific Pennsylvania Code regulations related to pharmacy and nursing services.
Plan Of Correction
1. The facility cannot correct the untimely action to justify the prescribing of two antidepressants. However, Resident #114 has an active Gradual Dose Reduction (GDR) in place since 02/03/25 to discontinue his Venlafaxine, removing the antidepressant duplicate therapy. The facility cannot correct the delay in the physician response to pharmacist recommendation. Medication was discontinued on 01/08/2025. Resident #130 has documented clinical rationale for the continuation of Zyprexa as ordered. 2. The DON completed an audit of in-house residents presently on duplicate antidepressant medications on 02/07/2025. Listing reviewed with consulting pharmacist. Consulting pharmacist to issue medication regimen reviews to the appropriate physician to document the clinical rationale justifying the continued prescribing of duplicate antidepressant medication. 3. The DON or designee will re-educate the consulting pharmacist, attending physicians, and medical directors to Tag F 0756 and CMS 483.45(c)(1)(2)(4)(5) requirements, along with the facility's Monthly Medication Regimen Review Policy. 4. The DON or designee will review the monthly medication reviews sent to Elan Skilled by the consulting pharmacist and compare them to the listing of new residents receiving duplicate antidepressant therapy to ensure compliance with CMS 483.45(c)(1)(2)(4)(5) and facility policy. This review will take place for the next three months. Audit results will be reported to the Quality Assurance Performance Improvement committee to determine compliance.