Failure to Document Rationale for Not Implementing Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations regarding gradual dose reductions (GDR) and medication regimen reviews were properly reviewed and implemented by the attending physicians or that appropriate, patient-specific rationales were documented when recommendations were not followed. In multiple cases, the medical director or attending physician either disagreed with the pharmacist's recommendation or chose to maintain the current medication regimen, but did not provide the required rationale with patient-specific information in the residents' medical records. For several residents with psychiatric diagnoses such as anxiety disorder, depression, major depressive disorder, panic disorder, and psychotic disorder, the pharmacist made recommendations to evaluate the necessity of ongoing psychotropic and anxiolytic medications, including sertraline, trazodone, escitalopram, hydroxyzine, buspirone, lorazepam, mirtazapine, and Nuplazid. Despite these recommendations, the medical director or provider often marked disagreement or chose to maintain the current dose, but failed to elaborate with patient-specific reasons for not attempting a GDR or discontinuation, as required by federal guidelines. This pattern was observed across multiple residents, with forms signed and dated by the provider but lacking the necessary documentation of clinical justification. Interviews with the Director of Nursing (DON) confirmed that the pharmacist's recommendations were not implemented and that the required rationales for not performing GDRs were not provided in the medical records. The documentation reviewed included medication administration records, physician orders, pharmacist recommendations, and summary reports, all of which consistently showed the absence of patient-specific rationales when recommendations for dose reduction or medication discontinuation were declined by the provider.