Failure to Act on Pharmacist Recommendations and Missing Medication Review
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were acted upon in a timely manner for two residents reviewed for unnecessary medication use. For one resident with diagnoses including hallucinations, delusions, anxiety, and schizophrenia, the facility was unable to provide documentation of a required monthly medication regimen review for June, as confirmed by the administrator. This resident was prescribed multiple antipsychotic and antidepressant medications, and the absence of the June review indicated a lapse in the facility's process for ensuring regular pharmacist oversight. For another resident with intact cognition and psychiatric symptoms, the consulting pharmacist made a recommendation for a gradual dose reduction (GDR) of trazodone, requesting physician review and response. However, the physician did not sign or indicate acceptance or rejection of the recommendation, and there was no documentation of a patient-specific rationale if the recommendation was contraindicated. The assistant director of nursing confirmed that the recommendation was sent to the provider but no response was received, and there was uncertainty about whether any follow-up was attempted. Additionally, the facility was unable to provide a policy on pharmacy recommendations when requested.