Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) were attempted for a resident receiving psychotropic medications. Record review showed that the resident, who had diagnoses including renal insufficiency, Alzheimer's dementia, anxiety disorder, and adjustment disorder, was prescribed multiple psychotropic medications such as buspirone, mirtazapine, and sertraline. The resident exhibited behaviors such as delusions, verbal and physical outbursts, rejection of care, wandering, and urinary incontinence, and was unable to participate in a Brief Interview for Mental Status exam. Despite these conditions and ongoing use of psychotropic medications, there was no evidence in the medical record that a GDR had been attempted in the past year. Additionally, there were no physician orders or documented rationales indicating that a GDR was contraindicated for this resident. Interviews with the DON confirmed that no documentation of a GDR or physician rationale for not attempting a GDR could be found for this resident.