Failure to Ensure Proper Notification and Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the consultant pharmacist notified the physician or the director of nursing regarding the need for further documentation about the continued use of Risperidone for a resident with an unapproved diagnosis. The resident in question had diagnoses including Lewy body dementia, anxiety disorder, recurrent major depressive disorder, and impulse disorder. The resident's care plan required monthly medication reviews by the consultant pharmacist and physician, as well as documentation of gradual dose reduction attempts and the physician's response. The physician's order specified Risperidone for Lewy Body Dementia with behavioral disturbance, but this is an unapproved diagnosis for the medication, and no rationale for its use was documented by the physician. During the review, it was found that the consultant pharmacist had requested the diagnosis for the use of Risperidone, and the physician responded with the unapproved diagnosis. However, the consultant pharmacist did not follow up to notify the physician or the director of nursing about the need for further documentation to justify the continued use of Risperidone for this unapproved indication. Additionally, the facility was unable to provide a policy on pharmacy reviews when requested. These actions and omissions resulted in a failure to comply with requirements for monthly drug regimen reviews and proper documentation for the use of antipsychotic medications.