Failure to Complete and Document Required Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a Gradual Dose Reduction (GDR) was completed for one resident reviewed for unnecessary medications. The resident, who was moderately cognitively impaired, was prescribed Sertraline for depression and Zyprexa for dementia with psychotic disturbance. Documentation showed only one GDR attempt for Sertraline in over two years and only one GDR attempt for Zyprexa in the previous thirteen months. There was no supporting documentation in the electronic health record (EHR) for a GDR on the date indicated in the Minimum Data Set (MDS), nor was there documentation from the pharmacy or provider requesting a GDR or supporting contraindications for GDR. Staff interviews revealed confusion regarding the requirements for GDRs, with staff referencing facility policy and pharmacy guidelines but unable to provide documentation supporting their practices. The facility's policy did not specify time frame requirements for GDR attempts, and no further documentation was provided to support that appropriate GDRs or contraindications had been addressed for the resident's psychotropic medications.