Failure to Update Medical Records Following Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to act upon pharmacist recommendations regarding the use of antipsychotic medications for two residents. In both cases, the consulting pharmacist identified that the residents were receiving quetiapine fumarate without an appropriate diagnosis to support its use, as outlined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The pharmacists provided recommendations to update the residents' medical records with appropriate indications or diagnoses. The physicians for both residents reviewed and agreed with the recommendations, indicating that the records should be updated with the necessary diagnoses. Despite physician agreement, the facility did not update the medical records to reflect the appropriate indications for the continued use of quetiapine fumarate. One resident, who was severely cognitively impaired and had no behavioral symptoms, continued to receive quetiapine without a supporting diagnosis in the record. The other resident, who was cognitively intact and independent in activities of daily living, also continued to receive quetiapine for agitation, but the agreed-upon diagnosis was not added to the medical record. Interviews with the Director of Nursing confirmed that the facility did not act on the pharmacist's recommendations in either case.