Failure to Communicate Pharmacist's Medication Recommendation to Physician
Penalty
Summary
The facility failed to inform the physician of the consultant pharmacist's recommendation regarding the administration of sertraline for a resident. The pharmacist's note, dated 4/30/2025, advised the attending physician to evaluate the need for discontinuation or gradual dose reduction of sertraline, in accordance with federal nursing facility regulations. However, the Assistant Director of Nursing (ADON) confirmed that this recommendation was not communicated to or reviewed by the physician. Additionally, there was no documentation found indicating that a gradual dose reduction had been implemented for the resident. The resident involved had a history of diabetes mellitus, schizophrenia, and chronic kidney disease, and had been receiving sertraline 50 mg daily for depression. The facility's policy required that residents on psychotropic medications receive gradual dose reductions unless clinically contraindicated. The Director of Nursing (DON) acknowledged that failure to provide the physician with the pharmacist's recommendations could result in the resident continuing to receive unnecessary medication.