Failure to Identify and Report Inappropriate Antipsychotic Use by Consultant Pharmacist
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of appropriate Centers for Medicare and Medicaid Services (CMS) approved indications for the use of antipsychotic medications in three residents. Multiple monthly drug regimen reviews were conducted by the CP, but the reviews did not identify or report that antipsychotic medications, such as Olanzapine (Zyprexa) and Quetiapine (Seroquel), were being prescribed for diagnoses that are not CMS-approved indications, such as dementia, mood disorder, and depression. The facility's policy required the CP to complete a monthly review for each resident and report irregular findings within 72 hours, but this was not followed in these cases. One resident with severe cognitive impairment and multiple diagnoses, including dementia and mood disorder, received Olanzapine for extended periods under various orders, all lacking a CMS-approved indication. The CP's monthly reviews from January 2024 through March 2025 did not identify or report this inappropriate use. Another resident with dementia, major depressive disorder, Parkinson's disease, and bipolar disorder received Seroquel for agitation and bipolar disorder, but the orders also lacked CMS-approved indications for use in dementia. The CP again failed to identify or report these irregularities during the monthly reviews. A third resident with dementia, depression, and hypertension was prescribed Seroquel for agitation and later for depression, without a physician-documented rationale for these indications. Although the CP eventually recommended a change in the medication indication, there was still no documentation of an appropriate rationale, and the facility could not provide one when requested. Interviews with nursing staff and administrative nurses confirmed that the use of antipsychotic medications for mood, dementia, or depression alone was not appropriate and that the CP was expected to report such irregularities, which did not occur as required by facility policy.