Failure to Document Gradual Dose Reduction or Clinical Justification for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a gradual dose reduction (GDR) or a clinical justification for the continued use of a psychotropic medication was documented for one resident reviewed for unnecessary medication use. The resident, who had moderate cognitive impairment and diagnoses including bipolar disorder and anxiety, was receiving both an antipsychotic (haloperidol) and an antidepressant (Zoloft). The medical record indicated that the last GDR attempt for psychotropic medications was performed over a year prior, and there was no documentation that a GDR was clinically contraindicated or that the resident was on the lowest effective dose for haloperidol during the past year. Interviews with facility staff revealed that medication reviews were conducted regularly, but nursing staff relied on the pharmacy consultant to recommend GDRs rather than proactively monitoring when GDRs were due. The pharmacy consultant stated that GDRs were performed twice a year for new medications and annually for established medications, with the last attempt documented as occurring several months prior. The facility's policy required that drug regimens be free from unnecessary drugs, including those used in excessive doses or durations or without adequate indications, but this standard was not met in the resident's case.