Failure to Act on Monthly Medication Reviews
Penalty
Summary
The facility failed to ensure that monthly medication reviews were acted upon by the physician and did not have a process in place to address these reviews in a timely manner. This deficiency affected four residents who were part of a sample of 32. For one resident, the attending physician did not document a clinical rationale for not attempting a gradual dose reduction (GDR) of Zoloft, despite multiple requests from the pharmacist over several months. Similarly, another resident's medication review for Lexapro also lacked a documented rationale for not attempting a GDR, with repeated requests from the pharmacist going unaddressed. Additionally, a resident continued to have an active order for hydroxyzine despite recommendations from the pharmacist to discontinue it, which were not acted upon over several months. Another resident had an as-needed lorazepam order without criteria for use beyond 14 days, and this issue was not addressed despite repeated recommendations. The Director of Nursing acknowledged the oversight, noting that the previous DON left abruptly, and she was initially unaware of the procedures for handling medication review forms. The facility's policy requires a response to every pharmacist recommendation, but this was not adhered to in these cases.