Failure to Address Pharmacy Recommendations for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding medication management were addressed by the physician for one resident reviewed for unnecessary medications. Specifically, a resident with Parkinson's disease and difficulty walking was prescribed trazodone, an antidepressant, without a documented diagnosis or clinical rationale for its use. Pharmacy reviews in both June and July identified the lack of an appropriate diagnosis for the new psychotropic medication and recommended that a diagnosis be provided. Despite these recommendations, the resident continued to receive trazodone for 29 days without the required documentation. Interviews with the facility's pharmacist confirmed that monthly reviews were conducted to ensure appropriate clinical diagnoses for all medications, including psychotropics, and acknowledged the absence of a diagnosis for trazodone. The Director of Nursing Services also recognized a delay in documenting clinical rationales for medications and confirmed that the pharmacy's recommendation was not followed up on in a timely manner.