Failure to Define Behaviors and Perform Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to properly identify and define specific problematic behaviors related to the use of quetiapine, an antipsychotic medication, for a resident diagnosed with dementia and psychosis. Documentation across the resident's physician orders, care plan, informed consent, and medication administration record was inconsistent, with different descriptions of the behaviors justifying the use of quetiapine. This inconsistency made it unclear why the medication was being used and whether its continued use was necessary for the resident. Additionally, the facility did not perform a required gradual dose reduction (GDR) for the resident's quetiapine therapy. Although the consultant pharmacist recommended a GDR, there was no evidence that the physician considered or responded to this recommendation, nor was there documentation of any clinical rationale for not attempting a GDR. The resident's dose of quetiapine remained unchanged since its initial prescription, and there was no record of psychiatric care or evaluation regarding the ongoing need for the medication. The facility's own policy requires that psychotropic medications be used only for specific, documented behaviors and that GDRs be attempted regularly unless clinically contraindicated. Despite this, the facility did not ensure that the use of quetiapine for this resident was clearly justified or that efforts were made to reduce the dosage as required. The Director of Nursing acknowledged these failures, noting the lack of clear documentation and follow-up regarding the use and monitoring of psychotropic medication for the resident.