Failure to Address GDR Requests and Communicate Psych NP Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was free from unnecessary drugs. Specifically, there was no evidence that pharmacy requests for gradual dose reductions (GDR) for medications including Risperidone, Seroquel, Cymbalta, and Temazepam were addressed by the physician over the past year. The resident in question had a history of multiple psychiatric diagnoses, including insomnia, major depressive disorder, bipolar disorder, and anxiety disorder, and was assessed as having moderate cognitive impairment. Despite ongoing orders for these medications, the required pharmacy GDR requests were not documented as being communicated to or considered by the physician. Additionally, the facility did not ensure that recommendations from a psychiatric nurse practitioner (Psych NP) to decrease the dosage of Risperidone were communicated to the physician. Progress notes from the Psych NP included recommendations to reduce the medication, but there was no evidence in the medical record that these recommendations were sent to the physician or that any physician response was received. Interviews with the DON and ADON confirmed the lack of documentation and communication regarding both the pharmacy GDR requests and the Psych NP's recommendations.