Failure to Act on Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the consultant pharmacist were acted upon for a resident whose medications were reviewed. Specifically, recommendations from the pharmacy consultant regarding the use of Haldol, an antipsychotic medication, were not followed. The consultant pharmacist had recommended that an approved psychiatric diagnosis be documented to support the continued use of Haldol and that an informed consent form be obtained and placed in the resident's medical record. However, the medical record did not contain the required consent for Haldol until several months after the medication was ordered, and there was no documentation of a psychiatric evaluation to justify its use during that period. The resident involved had a history of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a traumatic subdural hemorrhage. The resident was admitted and re-admitted to the facility, and the Minimum Data Set (MDS) indicated severe cognitive impairment with no behavioral symptoms or indicators of psychosis. Despite this, Haldol was ordered and administered without the necessary supporting documentation, including a psychiatric evaluation and informed consent, as required by facility policy and regulatory guidelines. Interviews with facility staff, including the physician assistant, licensed vocational nurses, and the director of nursing, confirmed that the required evaluation and consent were not obtained prior to the administration of Haldol. Staff acknowledged that the proper procedures were not followed, and the documentation in the medical record was incomplete regarding the rationale for the use of the antipsychotic medication. Facility policies reviewed also emphasized the need for appropriate diagnosis, consent, and documentation when administering psychotropic medications, which were not adhered to in this case.