Failure to Document Rationale for Medication Regimen Review Decisions
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews were completed and responded to in a timely manner for two residents. For Resident 90, who has diagnoses including schizoaffective disorder and anxiety disorder, a pharmacist recommended a gradual dose reduction (GDR) for psychoactive medications. The attending physician disagreed with this recommendation but did not provide a rationale for the decision in the resident's medical record. An interview with the Director of Nursing (DON) confirmed the absence of documentation explaining the physician's disagreement with the GDR recommendation. Similarly, for Resident 144, who has diagnoses including depressive disorder and anxiety disorder, a pharmacist also recommended a GDR for psychoactive medications. The attending physician disagreed with the recommendation but again failed to provide a rationale or date the response. The DON confirmed that there was no documentation available to explain the physician's decision regarding the GDR recommendation for Resident 144. These deficiencies indicate a failure to comply with the requirement for documenting the rationale for not following a pharmacist's recommendation.
Plan Of Correction
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Residents 90's physician has updated a rationale for not attempting a GDR on a pharmacist recommended GDR for resident 90's psychoactive medications. Resident 144's physician has updated a rationale and response for disagreeing on a pharmacist recommended GDR for resident 144's psychoactive medications. 2. To identify other residents that have the potential to be affected, the DON/designee will audit pharmacist recommended GDRs for past 30 days to ensure physicians document a response and rationale for disagreeing with GDR or not attempting the GDR. 3. Physicians will be educated by the DON/designee on the importance of providing documentation on a rationale and a response to pharmacy recommended GDR's. 4. The DON/designee will conduct an audit 1x a month for 3 months on pharmacy recommended GDR's on psychoactive medications to ensure physicians provide documentation of a response and rationale for either not attempting the GDR or disagreeing with it. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.