Delayed Response to Pharmacy Recommendation for Medication Dose Adjustment
Penalty
Summary
The facility failed to ensure timely action on a pharmacy recommendation for a resident with multiple diagnoses, including severe cognitive impairment, heart failure, diabetes, non-Alzheimer's dementia, anxiety, and depression. The resident was prescribed citalopram at a dose of 40 mg twice daily, which exceeded the maximum recommended daily dose. On 02/15/25, the consulting pharmacist recommended reducing the dose to 40 mg per day, and the Nurse Practitioner agreed with this recommendation on 02/26/25. Despite the agreement, the resident continued to receive the higher dose of citalopram from 02/15/25 through 03/11/25, with the medication order only being changed on 03/12/25. The facility's policy required a response to pharmacy recommendations within 7 days, but this was not met. During an interview, the Clinical Corporate Support Nurse confirmed that pharmacy recommendations should be addressed in a timely manner and acknowledged that the medication order should have been changed sooner.