Failure to Recommend Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility's consultant pharmacist failed to recommend a gradual dose reduction (GDR) for a resident's psychotropic medication, specifically buspirone, despite facility policy requiring quarterly consideration of dosage reduction for such medications. The resident in question had diagnoses including anxiety disorder, hypertension, hallucinations, dementia, chronic pain, and depression, and was receiving both buspirone and bupropion for anxiety and depression. The resident's care plan included interventions for behaviors and side effects, and directed consultation with pharmacy and the physician regarding GDR when clinically appropriate. However, pharmacy reviews over several months documented no irregularities, and there was no evidence that a GDR was recommended or that the physician provided a risk versus benefit rationale for the continued use of buspirone. Observations showed the resident was able to take medications without difficulty and displayed calm behavior during interactions, though she was noted to be confused but able to answer most questions. Interviews confirmed that the pharmacist had not recommended a GDR and that the physician had not documented a rationale for ongoing use of the medication. The facility's policy required the pharmacist to report findings and make recommendations to the physician and DON, including assistance with GDR reviews, but this process was not followed for the resident's psychotropic medication regimen.