Failure to Ensure Physician Response to Pharmacist's Antipsychotic Medication Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician responded to the Consultant Pharmacist's (CP) recommendation regarding the use of an antipsychotic medication for a resident. The CP identified that the resident was receiving Seroquel, an antipsychotic, without an allowable diagnosis to support its use and requested a clinical rationale from the physician. Despite this recommendation, the physician did not provide a response or documentation addressing the CP's concern. The resident's medical record showed ongoing administration of Seroquel for mood management, with no evidence of a gradual dose reduction being considered or implemented since admission. The resident involved had a history of cerebral infarction, hemiplegia, anxiety, and symptoms involving emotional state, but maintained intact cognition and independence in functional abilities. The care plan directed staff to administer medications as ordered and monitor for side effects and behaviors. The facility's policy required timely physician response to CP recommendations, including documentation of review and actions taken, but this process was not followed in this case, resulting in the continued use of an antipsychotic without appropriate clinical justification.