Failure to Implement Physician-Directed Psychoactive Medication Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to ensure that psychoactive medication recommendations were implemented as directed by the physician for a resident with multiple complex diagnoses, including major depression and severe cognitive impairment. The resident was prescribed Venlafaxine ER 37.5 mg for major depressive disorder, and the care plan included monitoring for side effects, monthly pharmacy review, and implementation of physician recommendations regarding medication management. Despite a pharmacy consultant's recommendation for the physician to consider a gradual dose reduction (GDR) of the psychoactive medication, and the physician's response to involve psychiatric consultation, there was no documentation in the medical record that this recommendation or physician response was implemented. The Director of Nursing confirmed during an interview that the physician's response had not been carried out, resulting in a failure to follow through on medication management protocols for unnecessary drugs.