Failure to Address Pharmacist's Recommendations for Psychotropic Medication Dose Reductions
Penalty
Summary
The facility failed to ensure that a pharmacist's recommendations for gradual dose reductions of two psychotropic medications, quetiapine and clonazepam, were addressed for one resident. The pharmacist's medication regimen review, dated 10/9/24, included recommendations for gradual dose reductions, but the only documentation found was a handwritten note stating 'follows psych,' dated 10/16/24. During interviews, staff indicated that the previous Director of Nursing (DON), who was responsible for medication review follow-up, was no longer employed at the facility, and current staff were unable to locate any medical record documentation addressing the pharmacist's recommendations. Despite requests for documentation, none was provided prior to the end of the survey.