Physician Failed to Document Rationale for Declining Pharmacist's Medication Recommendation
Penalty
Summary
A deficiency was identified when the attending physician failed to document a clinical rationale for declining a consultant pharmacist's recommendation regarding a resident's medication regimen. The resident in question was admitted with diagnoses including unspecified dementia without behavioral disturbance, encephalopathy, respiratory failure, and a history of multiple falls. The pharmacist's monthly drug regimen review noted that the resident was receiving three or more central nervous system (CNS) active medications—specifically lorazepam, duloxetine, quetiapine, and tramadol—and had recently experienced a fall. The pharmacist recommended a gradual dose reduction (GDR) of duloxetine due to the risks associated with polypharmacy and recent fall history. The attending physician reviewed the pharmacist's recommendation but declined to implement the suggested GDR of duloxetine. However, the physician did not provide an acceptable clinical rationale in the resident's medical record to justify this decision. This omission was identified during a review of the clinical record and confirmed through staff interviews. The deficiency was discussed with the Nursing Home Administrator and Director of Nursing.