Failure to Implement Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to act upon a pharmacist's recommendations for a resident who was prescribed Olanzapine, an antipsychotic medication, for hallucinations. The pharmacist had recommended that, if the antipsychotic was to be continued, the medical record should be updated to include a list of symptoms or target behaviors and their impact on the resident, documentation that other causes and medications had been considered, evidence of individualized nonpharmacological interventions, and ongoing monitoring. A review of the resident's clinical record showed that these recommendations were not implemented, as there was no documentation of specific target behaviors, their impact, consideration of other causes or medications, or individualized nonpharmacological interventions. The Director of Nursing Services confirmed that the pharmacist's recommendations were not followed.