Failure to Respond to Pharmacist's GDR Recommendation for Psychotropic Medication
Penalty
Summary
The facility failed to respond to a consultant pharmacist's recommendation for a gradual dosage reduction (GDR) of quetiapine for a resident diagnosed with dementia and psychosis. The pharmacist made the recommendation on 2/5/25, and although the facility left a message with the psychiatrist on 2/9/25, there was no documented response from the physician or evidence of further follow-up. The resident's clinical record did not contain documentation of psychiatric care or any indication that a physician considered the GDR request, approved a lower dose, or provided a resident-specific clinical rationale for not attempting a GDR. Additionally, the facility did not clearly identify or document the specific behavioral issues related to the resident's use of quetiapine. The problematic behaviors listed in the physician's order and informed consent documentation differed from those in the care plan and medication administration record, making the rationale for continued use of quetiapine unclear. The Director of Nursing confirmed that a GDR was not performed and that there was no documentation to indicate that a GDR attempt was clinically contraindicated, as required by facility policy.