Failure to Address Pharmacist Recommendations and Inadequate Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to address recommendations made by the Consultant Pharmacist (CP) regarding the medication regimen of two residents with dementia and Alzheimer's disease. For one resident, the CP identified irregularities related to the administration of Midodrine, a medication prescribed for hypotension. Although the resident's blood pressure readings were within the physician-ordered parameters for administration on multiple occasions, the clinical record did not document that the physician was notified when the medication was not administered as ordered. The CP had reported these irregularities in the Monthly Medication Reviews, but there was no evidence that the facility acted on these recommendations or communicated with the physician as required. Additionally, both residents were prescribed antipsychotic medications for non-approved indications, specifically for dementia and Alzheimer's disease. The CP identified and reported these irregularities, noting the lack of appropriate physician documentation for the risk versus benefit analysis and the rationale for continued use of antipsychotics for these diagnoses. The facility was unable to provide documentation supporting the use of these medications for the residents, despite repeated recommendations from the CP. The care plans for both residents indicated monitoring for side effects and collaboration with the physician, but there was no evidence that the required documentation or physician engagement occurred. Interviews with nursing staff and administrative personnel revealed a lack of understanding regarding appropriate indications for antipsychotic medication use. Staff were unsure about the correct process for addressing CP recommendations and for ensuring physician orders were followed and documented. The facility's policies required the CP to review medication regimens monthly and communicate potential or actual problems to the physician and Director of Nursing, but these procedures were not effectively implemented, resulting in the identified deficiencies.