Failure to Ensure Gradual Dose Reduction and Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychoactive medications had appropriate gradual dose reductions (GDR) or documented clinical contraindications, and did not identify or document targeted behavioral symptoms for the use of psychotropic medications for two of five residents reviewed. For one resident with diagnoses including delusional disorder, heart failure, obesity, and sleep apnea, the clinical record showed ongoing use of sertraline, quetiapine, and trazodone. Pharmacy consultant recommendations for GDR were declined by the physician without a resident-specific risk-benefit analysis or clear statement of contraindication. The care plans lacked identification of targeted behaviors for the use of these medications, and documentation of delusions and hallucinations was not resident-specific. Observations and staff interviews confirmed the presence of hallucinations and delusions, but the clinical record did not contain specific or consistent documentation of these symptoms. Another resident with dementia, psychotic and mood disturbances, and anxiety was prescribed multiple psychotropic medications, including amitriptyline, duloxetine, and quetiapine. Pharmacy recommendations for GDR were also declined by the physician, with only a general statement that "risk outweighs benefit" and no detailed risk-benefit analysis. The care plans did not specify targeted behaviors or symptoms for the use of these medications. Documentation in the medication administration record indicated delusions, but lacked resident-specific details. Staff interviews revealed that the resident had not recently reported hallucinations or delusions, though some behaviors such as packing belongings and attempting to take a roommate's items were noted. The clinical record did not contain specific documentation of hallucinations or delusions, and the resident's family had previously refused GDRs, though some changes were eventually made. The facility's policy required that psychotropic medications be used only when medically necessary, with appropriate documentation and ongoing efforts to reduce dosages unless contraindicated. However, in both cases, the required documentation of medical necessity, targeted behaviors, and resident-specific contraindications for GDR was lacking. The deficiency was identified through observation, interview, and record review, demonstrating a failure to comply with regulatory requirements for the use of unnecessary drugs and psychotropic medication management.