Failure to Ensure Gradual Dose Reduction and Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary psychotropic medications and that proper procedures were followed regarding medication management. For one resident with a history of schizophrenia, cognitive communication deficit, and depression, the facility did not perform a required gradual dose reduction (GDR) for risperidone, despite a medication regimen review indicating that a GDR was due. Documentation showed that the resident had not exhibited symptoms such as hallucinations or behavioral disturbances for several months, yet the antipsychotic medication was continued at the same dosage without documented clinical justification or evidence of a GDR attempt. Additionally, the facility failed to obtain proper informed consent for the administration of alprazolam to another resident diagnosed with dementia, schizophrenia, and anxiety. Although the resident was taking anti-anxiety medication, the informed consent form was signed by the resident, who was documented as unable to make medical decisions, rather than by the responsible party (RP) designated to make such decisions. Both nursing staff and the interim director of nursing confirmed that the RP should have provided consent, and acknowledged that the lack of RP signature meant the resident and their representative may not have been fully informed about the medication being administered. Facility policy required that residents or their representatives be informed of the risks, benefits, and alternatives to psychotropic medications, and that documentation of this informed consent be maintained. In both cases, the facility did not adhere to its own policies and procedures regarding psychotropic medication management and informed consent, resulting in deficiencies related to medication safety and resident rights.