Failure to Attempt Gradual Dose Reductions for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications by not attempting or addressing Gradual Dose Reductions (GDRs) for their psychoactive medications. Facility policy required that behavior interventions be evaluated before using psychotropic medications, and that GDRs be attempted unless clinically contraindicated, in accordance with federal regulations. For both residents, who had diagnoses including dementia with behavioral disturbances, depression, and anxiety, there was no evidence in their medical records that GDRs were attempted or considered over the previous year for medications such as Lorazepam, Mirtazapine, Zoloft, Lexapro, and Trazadone. Record reviews showed that one resident was receiving Mirtazapine, Zoloft, and Lorazepam, while another was on Lexapro, Lorazepam, and Trazadone, with no documentation of GDRs being addressed. The Director of Nursing confirmed during interview that no GDRs had been attempted or addressed for these residents' psychoactive medications in the past year, which was inconsistent with both facility policy and regulatory requirements.