Failure to Communicate Pharmacy GDR Recommendation to Hospice Prescriber
Penalty
Summary
The facility failed to ensure that a pharmacy consultant's (PharmD) recommendation for a gradual dose reduction (GDR) of an antipsychotic medication was communicated to the hospice prescriber for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including dementia, visual hallucinations, psychotic disturbance, mood disturbance, and anxiety. The resident was receiving hospice care for vascular dementia following a stroke and had active orders for quetiapine fumarate, both as a routine and as-needed (PRN) medication for agitation and hallucinations. The PharmD reviewed the resident's medication regimen and recommended either discontinuing the PRN antipsychotic, issuing a new order with a specified duration and rationale, or adjusting the routine order, in accordance with regulations that PRN antipsychotic orders cannot exceed 14 days without direct prescriber evaluation. Despite this recommendation, there was no documentation in the resident's electronic medical record or hospice communication folder indicating that the recommendation had been reviewed or addressed by the hospice prescriber. Interviews with facility staff revealed a belief that GDRs for hospice residents were the responsibility of hospice providers, but the hospice nurse confirmed that the recommendation had not been received. Facility policy required staff to facilitate communication between the resident, family, and hospice employees, but this process was not followed, resulting in the PharmD's recommendation not being communicated or acted upon.