Failure to Document Clinical Rationale for Not Reducing Psychotropic Medications
Penalty
Summary
The facility failed to document a clinical rationale for not completing Gradual Dose Reductions (GDR) for psychotropic medications for two residents. Facility policy required that residents on psychotropic medications receive GDRs unless clinically contraindicated, and that any contraindication be documented. For one resident with dementia, anxiety, depression, and behavioral symptoms related to psychosis, the consultant pharmacist requested a dosage reduction for Seroquel and Paroxetine. The provider responded to the request after 45 days but did not document any clinical reason for not reducing the doses. For another resident with sleep disturbances and insomnia, the consultant pharmacist recommended a dosage reduction for Trazadone. The provider declined the reduction but again failed to document a clinical rationale. Interviews with nursing staff confirmed that the facility did not address pharmacist recommendations for GDRs in a timely manner and did not provide required documentation when declining to reduce psychotropic medication doses. The facility's policies outlined the need for regular review and documentation regarding psychotropic medication use, but these procedures were not followed for the two residents identified in the report.