Failure to Attempt or Document Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications underwent a gradual dose reduction (GDR) or had documentation supporting the clinical necessity for continued use of these medications. Record review showed that the resident had physician orders for Sertraline, an antidepressant, and Seroquel, an antipsychotic, both prescribed for depression and delusions. However, there was no evidence in the medical record of any attempts to perform a GDR or documentation indicating a contraindication to GDR for either medication. This was confirmed during an interview with the corporate nurse, who acknowledged the absence of required documentation. Facility policy requires that residents on psychotropic medications receive GDRs unless clinically contraindicated, but this was not followed in this case.