Failure to Obtain Physician Rationale for Continued Antipsychotic Use After Pharmacy Review
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a physician provided a rationale for the continued use of an antipsychotic medication after a consultant pharmacist requested review. One resident had a physician’s order for Zyprexa 5 mg at bedtime for the diagnosis of insomnia, starting on 09/27/24. A pharmaceutical consultant report dated 04/24/25 documented that the resident was receiving Zyprexa 5 mg for insomnia and noted that insomnia was not an approved diagnosis for Zyprexa per CMS guidelines. The pharmacist requested that the physician evaluate the routine use of this psychoactive medication, consider a gradual dose reduction (GDR), and, if a dose reduction was not desired, provide a rationale for its continued use. In the section of the report designated for the physician’s response, there was no order for a dose reduction and no documented rationale for continuing the current dose. Record review showed that the resident’s Zyprexa order remained active on the December 2025 MAR, and the medication continued to be administered, including on 12/01/25 and 12/02/25, with the diagnosis of insomnia unchanged. A medication order audit form showed the Zyprexa 5 mg order had been repeatedly reordered on multiple dates from 10/22/24 through 11/11/25. The facility’s policy on psychotropic medications, revised 12/03/25, required that residents receiving psychotropic medications have GDRs attempted at least twice within the first year in two separate quarters, with documentation of the resident’s response and physician rationale if the dose was returned to a prior level. During interview, the DON stated that pharmacy consultation reports are used to alert the physician to issues such as the need to attempt a GDR, acknowledged that the physician had not addressed the pharmacist’s concerns about Zyprexa, and confirmed that the physician had not followed the facility’s policy regarding GDRs or provided a rationale for continued use.
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