Failure to Complete Required GDR and Behavioral Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to complete an annual gradual dose reduction (GDR) for an antidepressant medication for a resident with diagnoses including depression, anxiety, and bipolar disorder. The clinical record showed that the last GDR for the resident's duloxetine was completed over a year ago, and there was no documentation of a more recent attempt, despite facility policy requiring annual GDRs after the first year of use. The pharmacy had recommended against a GDR, but the required documentation and process were not completed as per policy and CMS guidelines. Additionally, the facility did not document behavioral observations or the use of nonpharmacological interventions prior to increasing the resident's antipsychotic medication, aripiprazole. The resident's records, including behavior monitoring flow sheets and the MAR, lacked evidence of observed behaviors or attempted interventions before the medication increase. The DON confirmed the absence of this documentation and acknowledged the failure to follow required procedures.