Failure to Timely Address Pharmacy GDR Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a pharmacy consultant's recommendation regarding a resident's medication regimen. Specifically, a pharmacist recommended a Gradual Dose Reduction (GDR) for a resident's 25mg Zoloft prescription in May 2025, but there was no documented evidence that the physician addressed this recommendation until August 2025. Facility policy requires that such recommendations be addressed prior to the next monthly medication review, and a summary of all recommendations is to be provided to the DON and Medical Director each month. The resident involved was cognitively intact, required partial staff care, and was receiving an antianxiety medication at the time of the deficiency. This lapse was confirmed by the Nursing Home Administrator during an interview.