Lack of Physician Rationale for Not Following Pharmacist's Antidepressant Dose Reduction Recommendation
Penalty
Summary
The facility failed to ensure that a physician provided documentation of a clinical rationale for not following a consultant pharmacist's recommendation regarding a resident's antidepressant medication regimen. Specifically, a resident with diagnoses including dementia without behavioral disturbance, insomnia, and major depressive disorder had been prescribed escitalopram 20 mg daily since admission. The consultant pharmacist recommended a gradual dose reduction (GDR) of escitalopram, but the provider declined this recommendation, stating only that the resident had a good response and to maintain the current dose, without providing a clinical rationale for not attempting the GDR. Review of the resident's medical record confirmed that no clinical rationale was documented for declining the pharmacist's recommendation. Interviews with the DON and Medical Director further confirmed that the provider did not document a reason for not conducting a GDR, despite facility expectations that such rationale should be provided when a GDR is not attempted for antidepressant medications. This lack of documentation was identified during record review and staff interviews.