Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) of psychotropic medications were attempted when indicated for two residents. For one resident with diagnoses of major depression and insomnia, the medical record showed continued administration of lorazepam at 0.5mg twice daily, despite multiple recommendations from the Medical Director to reduce the dose to 0.25mg twice daily. The resident's medication administration records confirmed that the dose was never reduced, and interviews with nurse practitioners and the MDS Coordinator revealed a lack of communication and follow-through on the Medical Director's recommendations. The pharmacist also requested a GDR, but the response from the nurse practitioner was limited to a generic statement without resident-specific rationale, and no dose reduction was attempted. Another resident with dementia, major depression, anxiety, and insomnia was prescribed olanzapine for behavioral disturbances. The resident's care plan and medical records indicated no recent behavioral symptoms, yet a dose reduction of the antipsychotic had not been attempted. The pharmacist recommended a GDR, but the nurse practitioner's response was again limited to a generic statement, without documentation of specific behaviors, risk factors, or clinical rationale for maintaining the current dose. Interviews with staff confirmed that the documentation did not include individualized justification for not attempting a GDR. Facility policy required GDR attempts for psychotropic medications unless clinically contraindicated, with documentation of specific clinical rationale if a reduction was not attempted. The records and interviews demonstrated that these requirements were not met for the two residents, as there was a lack of individualized assessment and documentation regarding the continued use and dosing of psychotropic medications. This failure had the potential to contribute to avoidable side effects, including sedation, dizziness, and increased falls.