Failure to Ensure Timely Physician Response and Pharmacist Review for Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure compliance with its policy regarding timely physician response to pharmacist recommendations for gradual dose reduction (GDR) of an antidepressant medication. Specifically, a resident with a physician's order for Mirtazapine for depression was identified as needing a GDR review by the pharmacist on 12/28/24. However, the attending physician did not provide a response to this recommendation within the facility's required 30-day timeframe. The pharmacist followed up with the physician on 02/27/25, and a response was finally received on 03/05/25, well beyond the policy's deadline. Additionally, the facility did not ensure that the pharmacist identified the need for a possible GDR for the resident after the last documented GDR in May 2024. When asked by the surveyor, the DON confirmed that there were no further GDR reviews after 12/28/24, despite the next review being due in February 2025. No explanation for this lapse was provided before the survey exit.