Failure to Attempt or Document Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDRs) were attempted or that clinical rationales for not attempting GDRs were documented for two residents receiving psychotropic medications. For one resident with dementia, anxiety, drug-induced dyskinesia, and chronic pain, active orders for mirtazapine and quetiapine were in place. The consultant pharmacist recommended considering a GDR for one of the medications, but there was no documented response from the physician, nor was there any clinical rationale provided for not attempting a GDR. The Director of Nursing confirmed that no GDR was attempted and no rationale was documented. For another resident with major depression and significant behavioral symptoms, including disorganized thinking and physical behaviors towards others, there was an active order for Lexapro. The care plan indicated that a drug reduction would be done as recommended by the pharmacist and approved by the physician. However, the medical record contained no evidence that a GDR was attempted or that a clinical rationale for not attempting a GDR was documented. The DON stated that GDRs are only completed if identified by the pharmacist during monthly reviews, and confirmed the absence of documentation for this resident.