Failure to Ensure Adequate Monthly Pharmacist Medication Reviews and Documentation
Penalty
Summary
The facility failed to ensure that a licensed pharmacist adequately performed and documented monthly medication regimen reviews for several residents receiving psychotropic medications. For one resident, the pharmacist's review did not include all prescribed medications, specifically omitting Ativan, and lacked documentation of the risks versus benefits or rationale for continued use of psychotropic drugs. The physician declined a gradual dose reduction without providing clinical justification, and the resident continued on multiple psychotropic medications for extended periods without documented attempts at dose reduction. Staff interviews revealed concerns that the use of Ativan contributed to the resident's falls, including a hip fracture. Additionally, the facility was unable to provide monthly pharmacist medication regimen reviews for several other residents over the past year. This was attributed to issues with a previous pharmacy provider, which resulted in the facility being locked out of the system and unable to access historical documentation, including pharmacy reviews and recommendations. As a result, there was no evidence that appropriate monthly reviews or recommendations were completed to ensure residents were receiving suitable medications and dosages for their diagnoses.