Failure to Act on Pharmacy Recommendations and Inadequate Documentation of Clinical Rationale
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were appropriately acted upon and documented for two residents. For one resident with diagnoses including major depressive disorder, anxiety, and bipolar disorder, the December 2024 pharmacy review recommended a gradual dose reduction (GDR) for Zolpidem, Hydroxyzine, and Haloperidol. However, there was no evidence in the clinical record that the physician responded to this pharmacy recommendation, and facility staff were unable to locate documentation of a physician response. For another resident with depressive disorder and hypertension, the pharmacy made three separate recommendations over several months to attempt a GDR of Zolpidem 5 mg. Each time, the physician declined the recommendation, citing that the resident was being followed by psychiatric services. However, review of the clinical record revealed that the last psychiatric consultation occurred in August 2024, and there was no evidence of ongoing psychiatric follow-up during the periods when the GDR recommendations were made. Staff confirmed the absence of recent psychiatric consultation reports and acknowledged that declined pharmacy recommendations should have an appropriate clinical rationale.