Failure to Act on Pharmacy Recommendations for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the attending physician acted upon pharmacy recommendations for a resident whose medication regimen was reviewed for psychotropic medication. The resident, who was admitted with multiple diagnoses including Alzheimer's disease with early onset and dementia, was prescribed Seroquel for dementia with behavioral disturbances. The pharmacist, during the monthly drug regimen review, recommended assessing the risks versus benefits of continuing the medication and later suggested discontinuing it. However, there was no documentation in the resident's medical record indicating that the attending physician responded to these recommendations. The deficiency was identified through policy review, record review, and staff interviews. The facility's Medication Regimen Review Policy required the attending physician to document any medication irregularity and the actions taken to address it. Despite the pharmacist's recommendations documented on two separate occasions, the medical record lacked any response from the attending physician. The Director of Nursing confirmed that the recommendations were sent to the attending physician, but no response was received, indicating a lapse in the facility's adherence to its own policies and procedures.