Failure to Implement Physician-Ordered Psychotropic Dose Reduction
Penalty
No penalty information released
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Summary
A deficiency occurred when the facility failed to implement a physician's order to reduce the dosage of sertraline (Zoloft) for a resident as part of a gradual dose reduction recommended by the consultant pharmacist. The physician responded to the pharmacist's recommendation by ordering a decrease in the resident's Zoloft dosage from 100 mg to 75 mg daily. However, there was no documentation that this dosage reduction was carried out, and the resident continued to receive the original 100 mg daily dose. The Director of Nursing confirmed that the physician's order to decrease the medication was not implemented, despite facility procedures indicating such changes should be made the same day or the next day.