Failure to Document and Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including cerebral infarction, cognitive communication deficit, hemiplegia, hemiparesis, dysphagia, aphasia, and hypertension, was not provided with appropriate gradual dose reductions (GDR) or behavioral interventions for psychotropic medications as required. The resident had physician orders for Trazodone for insomnia and Divalproex Sodium (Depakote) for increased behaviors. Documentation showed that a clinical contraindication form for GDR of Trazodone was completed, but the section specifying the reason for the contraindication was left blank. There was no documentation of an attempted GDR or a clinical contraindication for the use of Divalproex Sodium. Interviews with staff revealed that the resident exhibited behaviors such as impatience, yelling, and a history of physical and verbal aggression, which were being monitored. The Divalproex was reportedly used for these behaviors, but no GDR attempt or clinical contraindication was documented. The process for GDR and documentation was discussed among staff, but the required rationale for not attempting a GDR, particularly for Divalproex, was not provided in the resident's record.