Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use without a gradual dose reduction (GDR) as required. The resident, who had diagnoses including anxiety disorder, hypertension, hallucinations, dementia, chronic pain, and depression, was prescribed buspirone for anxiety and depression. Despite the care plan directing staff to consult with the pharmacy and physician regarding dosage reduction at least quarterly, and to discuss the ongoing need for the medication, there was no evidence that a GDR was attempted or that the physician provided a documented risk versus benefit rationale for the continued use of buspirone. The consultant pharmacist's medication reviews over several months did not identify any irregularities or recommend a GDR, and the physician's orders continued the medication without documented justification. Observations showed the resident receiving and taking the prescribed medications without issue, and staff interviews confirmed that no GDR had been recommended or rationale documented for ongoing use. The facility's own policy required that residents on psychotropic medications receive GDR and behavioral interventions unless clinically contraindicated, with GDR attempts to be made within the first year of prescription and in at least two separate quarters. These requirements were not met for this resident, resulting in a deficiency related to the administration of unnecessary psychotropic medication.