Failure to Document Physician Review of Pharmacist's Psychotropic Medication Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician documented in the medical record that a drug regimen irregularity identified by the consultant pharmacist had been reviewed and addressed for a resident receiving psychotropic medication. Specifically, the consultant pharmacist recommended evaluating and considering a gradual dose reduction of Prozac, which the resident had been receiving daily. The recommendation was not reviewed or signed by the resident's attending physician, and there was no documentation in the resident's medical record indicating that the physician had considered or responded to the pharmacist's recommendation. Instead, the recommendation was signed by a nurse practitioner from a psychiatric consulting agency who was not the resident's attending physician or an authorized extender. The resident involved had severe cognitive impairment and multiple psychiatric diagnoses, including dementia, adjustment disorder with depressed mood, recurrent depressive disorders, and generalized anxiety disorder. The care plan indicated the need for the lowest therapeutic dose of psychotropic medications and required consultation with the pharmacist and physician regarding dose reduction. Interviews with facility staff confirmed that the process for ensuring physician review of pharmacist recommendations was not followed, and there was no documentation of any discussion or decision by the attending physician regarding the recommended gradual dose reduction.