Failure to Document Rationale for Declining Pharmacy Recommendations for Psychotropic Medication Dose Reductions
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's recommendations for gradual dose reductions (GDR) of psychotropic medications were properly addressed and documented for two residents. In the first case, a resident with significant cognitive impairment and multiple psychotropic medications had pharmacy recommendations for GDRs, but the attending physician declined these recommendations without providing a patient-specific rationale, as required by facility policy. The physician simply checked a box indicating that a GDR was clinically contraindicated but left the rationale section blank. Additionally, the facility was unable to provide documentation of a previous pharmacy recommendation for this resident, despite requests from surveyors. In the second case, another resident with dementia, major depression, and mood disorder was prescribed Seroquel for mood disorder. The pharmacy recommended GDRs on two occasions, but the physician declined these recommendations. On one occasion, the only rationale provided was a family request, and on the other, no rationale was documented at all. Facility policy and the State Operations Manual require that a specific explanation be provided when recommendations are rejected, but this was not done. Both cases demonstrate that the facility did not follow its own policies and procedures regarding medication regimen reviews and the documentation of physician decisions related to pharmacy recommendations. The lack of patient-specific rationales for declining GDRs and the absence of required documentation were directly observed and confirmed through staff interviews, clinical record reviews, and facility documentation.