Failure to Document and Monitor Psychotropic Medication Use and GDR
Penalty
Summary
The facility failed to properly document and monitor the use of psychotropic medications for several residents, specifically neglecting to record why Gradual Dose Reduction (GDR) was contraindicated and not providing specific indications for administering these medications. For one resident, Seroquel was initiated due to increased agitation, but there was no ongoing documentation of behavioral monitoring or side effects before and after starting the medication. Nursing notes indicated the resident was frequently sleepy, yet there was no evidence of continued assessment or documentation as required by the facility's own policy. Another resident was observed sleeping frequently, with both staff and the resident's representative noting excessive drowsiness. The pharmacy had recommended a GDR for this resident's psychotropic medications, but the attending physician did not provide a clinical rationale for declining the reduction and failed to follow up on a stated plan to attempt a GDR. Additionally, the physician's notes did not specify the ongoing indication for the medication, nor was there documentation of any GDR attempts after the first year of use, as confirmed by the DON and the physician. A third resident was prescribed multiple psychotropic medications, including antipsychotics, anti-anxiety, and antidepressants, but the facility did not have orders in place to monitor or document side effects. Review of the resident's behavior monitoring sheets revealed that side effects were only documented on one day out of an entire month, despite daily documentation of behaviors. The DON confirmed the lack of orders and documentation for monitoring side effects, and the pharmacist had not identified this gap. These deficiencies were identified through observations, record reviews, and staff interviews.