Failure to Identify and Report Inappropriate Antipsychotic Use and Lack of Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure that the consultant pharmacist (CP) identified and reported the use of antipsychotic medications without appropriate indications for two residents diagnosed with dementia. For one resident with diagnoses including psychosis, Alzheimer's disease, and dementia with agitation, the medical record showed multiple orders for Seroquel, an antipsychotic, with the indication listed as psychosis. However, there was no appropriate indication documented for the use of this medication in a resident with dementia, and the CP did not recommend a gradual dose reduction (GDR) or address the lack of indication in their monthly reviews. The care plan directed staff to consult with pharmacy and the physician regarding dosage reduction and to discuss ongoing need for the medication, but these steps were not documented as completed. Interviews with nursing staff revealed uncertainty about appropriate indications for antipsychotic use in dementia and the process for communicating pharmacy review findings to physicians. A second resident, with diagnoses including dementia, cognitive communication deficit, and psychosis, was also prescribed Seroquel for psychosis. The resident's care plan included instructions for staff to consult with pharmacy and the physician to consider dosage reduction quarterly and to review behaviors and interventions. Despite this, the CP's monthly medication reviews over a year did not include recommendations regarding the inappropriate indication for the antipsychotic medication. Nursing staff interviews indicated a lack of clarity about their roles in acting on pharmacy reviews and ensuring correct indications for psychotropic medications were communicated to the physician. Facility policies required the pharmacist to report any irregularities to the attending physician, the medical record, and the director of nursing, and for the physician to document review and actions taken. The policies also emphasized the need for adequate documentation of medication indications and the use of non-pharmacological interventions. Despite these policies, the facility did not ensure that the CP identified or reported the lack of appropriate indications for antipsychotic use or recommended GDRs, nor did the physician document risk versus benefit for continued use in one case. These failures resulted in the continued administration of antipsychotic medications without proper justification or review.