Lack of Physician Response to Pharmacist GDR and MRR Recommendations for Psychotropic/PRN Antipsychotic Use
Penalty
Summary
Surveyors identified a failure to ensure physician response to a pharmacist’s Gradual Dose Reduction (GDR) and Medication/Drug Regimen Review (MRR/DRR) recommendations for a resident receiving multiple psychotropic and PRN antipsychotic-related medications. The facility’s Pharmacy Services policy required pharmaceutical services that meet each resident’s needs and comply with state and federal requirements, including pharmacist collaboration and guidance on medication issues. Despite this, the pharmacist’s documented recommendations and regulatory reminders were not followed up with documented physician review or response as required by facility procedures. The resident involved was admitted with anxiety, a personality disorder, and hospice care for severe protein-calorie malnutrition, and had multiple psychotropic and related medications ordered, including lorazepam (scheduled and PRN), olanzapine, quetiapine, and escitalopram. A pharmacy review note dated 12/18/25 documented that the resident was receiving several psychotropic medications due for review and included a specific GDR recommendation to decrease lorazepam, along with multiple sections for the physician to indicate whether a GDR was clinically contraindicated or whether target symptoms had returned or worsened. All physician response sections on this form were left blank, and there was no documentation in nursing notes or physician progress notes indicating that the physician had reviewed or agreed/disagreed with the pharmacist’s GDR recommendations. A subsequent pharmacy review note dated 1/21/26 documented that the resident had been recently started on PRN lorazepam orders and that this was a second attempt to reduce the PRN medication. The pharmacist cited CMS regulation 483.45(e)(5) regarding the 14-day maximum duration for PRN antipsychotic orders and requested discontinuation of the current PRN antipsychotic-related orders unless specific evaluation and documentation requirements were met. The form again contained blank lines for the physician to discontinue the PRN medication or otherwise comply with CMS guidelines, but there was no documentation in the resident’s nursing notes or physician progress notes that the physician reviewed or responded to these recommendations. The physician’s monthly progress note for the resident contained no medication changes and no indication that the pharmacy recommendations or GDR had been reviewed. During interviews, the DON acknowledged responsibility for oversight of the pharmacy monthly review and confirmed that pharmacy DRR and GDR recommendations had not been followed up by nursing staff to obtain a physician response, and that the facility did not have a physician’s response documented for the resident’s GDR recommendations.
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