Delayed Physician Response to Pharmacy Medication Recommendation
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding a resident's medication regimen were reviewed and responded to in a timely manner by the physician. Specifically, a resident with diagnoses including cerebral infarction, schizoaffective disorder, major depression, hemiplegia, anxiety disorder, and chronic pain syndrome was receiving multiple medications, including antipsychotic and antidepressant drugs. The pharmacy made a recommendation for a dose reduction of Risperidone, a psychoactive medication, on 02/18/25. However, there was no documentation of a physician response to this recommendation until 04/07/25, when the physician indicated not to reduce the medication. Review of the resident's medical record, treatment records, progress notes, and physician orders confirmed the delay in response. The DON verified that the recommendation was made and acknowledged the response was not timely, despite the psychiatrist visiting every six weeks and the nurse practitioner being present more frequently. Facility policy required staff and practitioners to seek appropriate dosing and duration for each medication to minimize adverse consequences, but this process was not followed in this instance.