Failure to Document Clinical Rationale and Monitor Medication Irregularities
Penalty
Summary
The facility failed to ensure that a physician documented an adequate clinical rationale for denying a gradual dose reduction for a resident prescribed antipsychotic and antidepressant medications. Specifically, the physician declined the pharmacist's recommendation for a gradual dose reduction of Seroquel and Escitalopram, providing only the single word 'severity' as justification, which did not meet the facility's policy requirement for a valid clinical rationale. This was confirmed by the Director of Nursing, who acknowledged the lack of an adequate response from the physician. Additionally, the facility's consultant pharmacist did not identify or report irregularities related to the monitoring of prescribed medications for two residents. One resident, prescribed Levothyroxine, did not have appropriate monitoring of thyroid levels identified or reported by the pharmacist. Another resident, prescribed Atorvastatin Calcium, did not have the need for lipid panel monitoring identified or reported. The Regional Director of Clinical confirmed that these irregularities related to necessary lab work monitoring were not recognized by the pharmacist during the monthly drug regimen review.