Failure to Implement GDR and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to perform gradual dose reductions (GDR) for psychotropic medications in two residents. Despite recommendations from the consultant pharmacist and agreement from the psychiatric nurse practitioner (NP), the facility did not implement the changes in medication dosages for these residents. This oversight resulted in the residents continuing to receive higher doses of medications than necessary, increasing the risk of adverse effects. The facility also did not limit the duration of PRN lorazepam for a resident to 14 days or document a longer duration with a clinical rationale. This failure to adhere to the recommended duration for PRN medications increased the risk of the resident receiving the medication when it was no longer clinically appropriate, potentially leading to adverse effects. Additionally, the facility did not ensure that an antipsychotic medication was used for a clear indication or diagnosed condition for another resident. The facility also failed to monitor and document target behaviors related to the use of this medication. Furthermore, the facility allowed the simultaneous use of two antidepressants without clinical justification for a resident, increasing the risk of adverse effects.
Plan Of Correction
The Director of Nursing/designee audited the physician orders for psychotropic medications of all residents to identify residents who may be potentially affected by the facility practice on 3/6/2025. Thirty-five residents with psychotherapeutic medication therapy were audited. Five of 35 residents required the licensed nurse to clarify the physician's order with resident-specific targeted behaviors, stop date, duplicate medication therapy, and monitoring of targeted behaviors. The Director of Social Services/designee audited resident records who receive psychotherapeutic medications on 3/6/2025 to identify residents who do not have documented evidence of a gradual dose reduction in the medical record. Thirty-five residents receiving psychotherapeutic medications were audited. Two of 35 residents required a gradual dose reduction. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The IDT will review and revise the care plans of all residents with psychotherapeutic medication therapy to ensure care plans include resident-specific targeted behaviors and justification for dual medication therapy when indicated on 3/6/2025. The Director of Nursing/designee will re-educate licensed nurses and the IDT on the facility policies and procedures Unnecessary Medications, including required gradual dose reduction, justification when dual medication therapy is indicated, ensuring PRN medications have a stop date, and monitoring clearly defined behaviors in the medical record on or before 3/21/2025. The Director of Medical Records will audit the orders of residents' psychotropic medications to verify the order includes a stop date for PRN medications, diagnosis, targeted behavior(s), and targeted behavior, and provide copies of the audits to the Director of Nursing for tracking and trending analysis and further follow-through as needed. The Director of Social Services will monitor resident physician order changes weekly to ensure residents using psychotropic medications have complete physician orders, including targeted behaviors, justification for dual medication therapy, stop dates, and clearly defined diagnosis to support the use of medication. The IDT will review the orders of residents at the onset of psychotherapeutic medication changes or admission, whichever comes first, to ensure complete physician orders including targeted behaviors, justification for dual medication therapy, stop dates, and a clearly defined diagnosis to support the use of medication. They will also identify opportunities for gradual dose reduction attempts five times weekly during the morning clinical meeting. The Director of Nursing/designee will re-educate licensed nurses and the IDT on the facility policies and procedures Unnecessary Medications, including required gradual dose reduction, justification when dual medication therapy is indicated, ensuring PRN medications have a stop date, and monitoring clearly defined behaviors in the medical record on or before 3/21/2025. The Director of Medical Records will audit the orders of residents' psychotropic medications to verify the order includes a stop date for PRN medications, diagnosis, targeted behavior(s), and targeted behavior, and provide copies of the audits to the Director of Nursing for tracking and trending analysis and further follow-through as needed. The Director of Social Services will monitor resident physician order changes weekly to ensure residents using psychotropic medications have complete physician orders, including targeted behaviors, justification for dual medication therapy, stop dates, and clearly defined diagnosis to support the use of medication. The IDT will review the orders of residents at the onset of psychotherapeutic medication changes or admission, whichever comes first, to ensure complete physician orders including targeted behaviors, justification for dual medication therapy, stop dates, and a clearly defined diagnosis to support the use of medication. They will also identify opportunities for gradual dose reduction attempts five times weekly during the morning clinical meeting. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development will monitor the completion of staff training during new hire orientation, and as needed, on the facility's unnecessary medication policy and procedure. The Pharmacy Consultant shall monitor the medication regimen of residents each month to identify the potential for unnecessary drug use and report the results to the Director of Nursing and QAA quarterly. The Director of Social Services will monitor the Medical Records verification of complete physician orders, track gradual dose reduction attempts, and identify opportunities for GDR, and clearly defined diagnosis for use. Variance to standard concerns identified will be reported to the Director of Nursing. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025.