Failure to Document and Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary knowledge and techniques for timely medication management for a resident with multiple complex diagnoses, including cancer, heart failure, renal insufficiency, psychiatric disorders, and substance abuse. The resident was prescribed several psychotropic medications, and a pharmacist recommended a gradual dose reduction (GDR) for one of these medications, Mirtazapine. The recommendation was agreed upon by the facility's Nurse Practitioner, but there was no documentation indicating that the charge nurse received or processed the order, nor was there evidence of clarification or implementation of the GDR in the resident's medical record or Medication Administration Record (MAR). Interviews and record reviews revealed that the Director of Nursing (DON) was unaware that the recommended GDR had not been clarified or implemented, and the resident continued to receive the same dosage of Mirtazapine. The facility's medication order policy requires clear documentation, clarification, and transcription of medication orders, including changes in dosage, but these procedures were not followed in this case. This lapse resulted in a failure to ensure appropriate medication management and documentation for the resident.