Antidepressant Prescribed Without Documented Diagnosis
Penalty
Fine: $16,149
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency was identified when a resident was prescribed Duloxetine 60 mg for depression without a documented diagnosis of depression in the medical record. The medication order was active for ten days before being discontinued, and the care plan referenced the use of an antidepressant for depression. Additionally, a pharmacy review noted that the physician declined a gradual dose reduction because the antidepressant had been recently initiated. The lack of a documented diagnosis for depression in the resident's record, despite the presence of an active antidepressant order and related care plan entry, led to the deficiency finding.