Failure to Ensure Gradual Dose Reductions and Timely Review of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by both facility policy and federal regulations. For two residents with dementia and behavioral disturbances, the facility did not attempt or document Gradual Dose Reductions (GDRs) for their prescribed Seroquel, despite these residents having been on the medication since admission. The care plans and medication administration records for these residents showed ongoing use of antipsychotic medication without evidence of GDRs being addressed or attempted over the previous year. The Director of Nursing confirmed that no GDRs had been attempted or documented for these residents during this period. Additionally, another resident with severe cognitive impairment and multiple diagnoses, including dementia, heart disease, anxiety, and depression, was prescribed Haldol as needed for agitation, aggression, or restlessness. The as-needed order for Haldol was continued and administered beyond the 14-day limit without documented evaluation by the primary care provider for appropriateness, as required by facility policy. The Director of Nursing confirmed that the medication was administered past the 14-day limit. These actions were inconsistent with the facility's own policy and regulatory requirements regarding the use and review of psychotropic medications.