Failure to Document Rationale for Not Reducing Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a rationale was documented for not attempting a gradual dose reduction (GDR) of psychotropic medications for a resident. The resident, who had diagnoses including major depressive disorder, chronic kidney disease, urinary retention, and anxiety disorder, was receiving Zoloft, mirtazapine, and hydroxyzine. The consulting pharmacist recommended a GDR or, if not appropriate, required a documented explanation as to why a GDR would be detrimental. The physician reviewed and signed the pharmacy recommendations, indicating that a GDR was contraindicated, but did not provide any rationale for this decision. This omission was confirmed during an interview with the DON. Facility policy required that if a physician declined a pharmacist's recommendation, an explanation should be documented in the medical record, and if not, the DON should be notified and the issue brought to the QAPI committee. In this case, the required rationale was not documented, resulting in noncompliance with facility policy and regulatory expectations.