Failure to Implement Pharmacy Recommendation for Psychoactive Medication
Penalty
Summary
A deficiency occurred when the facility failed to act upon a pharmacy recommendation regarding the administration of a psychoactive medication for one resident. The resident, who was admitted with non-traumatic brain dysfunction and had moderate cognitive impairment as indicated by a BIMS score of 10 out of 15, was prescribed Lorazepam as needed without a stop date. The pharmacy conducted a drug regimen review and recommended that as-needed non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documented the specific condition being treated, the rationale for the extended use, and the duration of the order. The physician accepted this recommendation in writing. Despite the physician's acceptance, the order for Lorazepam remained active beyond the recommended 14-day period without a documented stop date, specific condition, or rationale for continued use. Review of the electronic medical record confirmed that the pharmacy's recommendation was not implemented, and the resident continued to receive Lorazepam past the recommended stop date. The deficiency was acknowledged by the Director of Nursing after being informed of the oversight.