Failure to Ensure Physician Review of Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not having gradual dose reduction (GDR) forms reviewed by a physician for two residents. For one resident with diagnoses including dementia, depression, anxiety, restlessness, and agitation, the annual Minimum Data Set (MDS) indicated the use of antipsychotic, antianxiety, and antidepressant medications. Although the MDS documented that a GDR was clinically contraindicated, the facility's GDR binder showed that multiple GDR forms for medications such as Haldol, Klonopin, Remeron, and Zoloft were not addressed by the physician. Another resident, who was on hospice and had diagnoses including depression, unspecified psychosis, anxiety, and senile degeneration of the brain, was also taking antipsychotic, antianxiety, and antidepressant medications. The quarterly MDS for this resident did not document that a GDR was clinically contraindicated. The facility's GDR binder revealed that GDR forms for medications including Seroquel, Celexa, and Lorazepam were not reviewed by the physician. The administrator confirmed that there was no documented evidence that the GDRs for these residents were addressed by the physician as required.