Failure to Document Gradual Dose Reduction or Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the consulting pharmacist (CP) identified the need for a gradual dose reduction (GDR) or provided medical justification for the continued use of psychotropic medications for one resident reviewed. The resident in question had moderate cognitive impairment, exhibited verbal behaviors, and had diagnoses including bipolar disorder and anxiety. The resident was prescribed both an antipsychotic (haloperidol) and an antidepressant (Zoloft), with the last documented GDR attempt occurring over a year prior. There was no documentation in the medical record of a GDR attempt or a clinical justification for the ongoing use of these medications within the past year. Monthly pharmacy reviews conducted from June 2024 to May 2025 did not identify any irregularities with the resident's psychotropic medications. Interviews with facility staff, including a registered nurse and the CP, confirmed that the resident's record lacked evidence of a recent GDR or a documented contraindication. The facility's policy required monthly reviews and recommendations for dosage reductions or modifications as appropriate, but this process was not followed for the resident in question.