Failure to Document Clinical Rationale for Not Attempting Gradual Dose Reductions
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were addressed in a timely manner and that clinical rationales for not attempting GDRs were documented, as required by policy. For one resident with a history of serious mental illness, including anxiety, bipolar disorder, and schizophrenia, the record showed ongoing administration of anti-psychotic, anti-depressant, and anti-anxiety medications. Although a GDR for Venlafaxine was marked as contraindicated by the prescriber, there was no documented clinical rationale provided for this decision. Another resident, admitted with diagnoses including stroke, high blood pressure, seizure disorder, and depression, was receiving daily antidepressant medications. The consultant pharmacist made multiple recommendations over several months for GDRs of Prozac and Trazadone. While the physician declined the GDRs, there was no evidence that a clinical rationale was documented to explain why the reductions were not clinically appropriate. Eventually, only the Trazadone dose was reduced, with no documentation regarding the Prozac. A third resident, with diagnoses of debility, heart failure, previous stroke, depression, and anemia, was also receiving daily antianxiety and antidepressant medications. The consultant pharmacist repeatedly recommended GDRs for Buspar and Remeron, but the prescriber did not order dose reductions and failed to provide a clinical rationale for not doing so. Interviews with the DON confirmed the absence of required documentation for all three residents, despite multiple pharmacist recommendations and follow-up communications.