Failure to Document Rationale for Declining Gradual Dose Reductions of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were attempted or that adequate, patient-specific rationales were documented when GDRs were not performed for three residents. For one resident with dementia, the pharmacist recommended a GDR for Seroquel, but the prescriber declined with only a general statement that the patient was stable, without further clinical justification. Another resident was on Sertraline, and the prescriber responded to the pharmacist's GDR recommendation with a vague comment that "things look good," lacking any specific rationale for maintaining the current dose. A third resident was receiving Duloxetine, Trazodone, and Provigil, and the prescriber declined the pharmacist's GDR recommendations for all three medications without documenting patient-specific reasons for not attempting dose reductions. Additionally, a staff member interviewed was unaware of the documentation requirements for supporting or declining GDRs and was behind on addressing pharmacy recommendations due to personal issues. The facility's policy requires that residents on psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated, with clinical rationales documented when GDRs are not attempted. However, the medical records reviewed did not contain adequate documentation to support the continued use of psychotropic medications at the current doses or to explain why GDRs were clinically contraindicated.