Failure to Document Clinical Rationale for Not Following Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to follow its own policy regarding the documentation and response to pharmacist recommendations for medication regimen reviews. According to facility policy, the consultant pharmacist is required to review each resident's medication regimen monthly and provide a written report to the attending physician for any identified medication irregularities. The attending physician is then required to document in the medical record that the irregularity has been reviewed and what, if any, action was taken. In the case reviewed, the pharmacist made recommendations regarding the use and dosage of Depakote for a resident with multiple psychiatric diagnoses, including obsessive-compulsive disorder, bipolar disorder, anxiety disorder, major depressive disorder, and schizoaffective disorder. The pharmacist's reviews noted that the indication for Depakote needed clarification, specifically whether it was being used for seizure control or for behavioral health purposes. The pharmacist also recommended an adjustment to the dosage, as the resident's levels were sub-therapeutic for seizures. In both instances, the provider's only written response was "no," without providing a clinical rationale or further explanation, as required by facility policy. The lack of documentation and rationale for not following the pharmacist's recommendations was confirmed during interviews with facility staff, including the DON, Case Manager, and the nurse practitioner responsible for the resident's care. The nurse practitioner acknowledged that while she had documented the indication for Depakote in her own notes, she had not provided this information on the medication regimen review forms, which would have made it accessible to the pharmacist. The facility's process for handling pharmacist recommendations involved the DON and Case Manager distributing recommendations to providers, but there was no further documentation if the provider chose not to implement the recommendation. This failure to document the clinical rationale for not following the pharmacist's recommendations resulted in noncompliance with facility policy and regulatory requirements.