Failure to Act on Pharmacy Consultant's Psychotropic Medication Recommendation
Penalty
Summary
The facility failed to ensure that pharmacy consultant recommendations regarding a gradual dose reduction (GDR) for a psychotropic medication were received and acted upon for a resident. Specifically, the pharmacy made a recommendation on 1/28/25 for a GDR of Quetiapine, but there was no documentation that this recommendation was communicated to the physician for review. The resident's medical record, including progress notes and medication administration records, did not reflect any physician notification or action taken in response to the pharmacy's recommendation. The resident involved was an older female with multiple complex diagnoses, including dementia, type 2 diabetes, atrial fibrillation, cognitive communication deficit, chronic pain, Parkinson's disease, and other significant health conditions. She was receiving Quetiapine 50 mg at bedtime as part of her treatment plan. The care plan indicated the need for regular monitoring of psychotropic medications, consultation with pharmacy and physician, and consideration of dose reduction when appropriate. However, the process for reviewing and acting on pharmacy recommendations was not followed in this case. Interviews with facility staff revealed that the failure to communicate the pharmacy's recommendation was due to staff turnover and discrepancies in the process of uploading recommendations for physician review. The responsibility for ensuring pharmacy recommendations were communicated to the physician was identified as belonging to the DON. Both the RCN and ADM acknowledged that the lack of communication could negatively affect residents, but there was no evidence that the required actions were taken for this resident.