Failure to Timely Address Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding a resident's medication regimen were addressed in a timely manner. A resident with multiple diagnoses, including major depressive disorder, dementia, hypertension, hypothyroidism, type 2 diabetes, malignant neoplasm of the pituitary gland, dysphagia, anxiety, and vitamin D deficiency, was prescribed Trazodone 25 mg at bedtime. The pharmacy identified that Trazodone was ordered for insomnia, but the resident did not have a documented diagnosis of insomnia, which is required for the use of psychotropic medications. Although the physician later agreed to add the diagnosis of insomnia, the medical record did not reflect this addition as of the review date. Facility staff, including a registered nurse, confirmed that the pharmacy's recommendation was not addressed promptly and the necessary diagnosis was not documented in the resident's medical record, contrary to facility policy.