Failure to Discontinue Unnecessary Psychotropic Medication After GDR Recommendation
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received the recommended gradual dose reduction (GDR) and discontinuation of a prescribed anti-anxiety medication, Lorazepam, as advised by the psychiatric nurse practitioner (NP). The resident, who was cognitively intact and had a history of anxiety disorder, diabetes, peripheral vascular disease, anemia, and chronic kidney disease, had no documented mood or behavior symptoms over multiple assessments. The facility's policy required regular review and reduction of psychotropic medications unless clinically contraindicated, with interdisciplinary team involvement and documentation of medication effects. Despite the psychiatric NP's recommendation to discontinue Lorazepam following a GDR, the order was not implemented. The NP documented the plan to discontinue the medication and communicated this to the unit manager, expecting the change to be completed the following day. However, the medication continued to be administered, and nursing staff consistently documented the absence of targeted behaviors that would justify ongoing use of Lorazepam. The care plan and behavior monitoring were updated, but the actual discontinuation order was not processed. Interviews with facility staff revealed a breakdown in communication and follow-through. The unit manager did not recall receiving a verbal order, and the social services director, who reviewed the NP's notes and updated the care plan, did not recall discussing the discontinuation recommendation. The psychiatric NP confirmed that medication changes are communicated during behavior meetings or directly to the nurse or unit manager, but no telephone order was written. This lapse resulted in the resident continuing to receive Lorazepam despite the absence of clinical indications and a clear recommendation for discontinuation.