Failure to Timely Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident prescribed psychotropic medication received a gradual dose reduction (GDR) as recommended by the pharmacy and signed by the provider. Specifically, the pharmacy recommended reducing the resident's Trazodone 50 mg dose to 37.5 mg at bedtime, and this recommendation was signed by the provider. However, the facility did not act on this recommendation for 14 days, and the resident continued to receive the higher dose during this period. Staff interviews revealed that the delay was attributed to waiting for approval from the resident's family member, who was reportedly unavailable due to illness. However, the family member later stated they were on vacation and had not received any calls from the facility regarding the GDR prior to being contacted. Facility policy requires timely action on pharmacy recommendations, but this was not followed in this instance.