Failure to Conduct Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to conduct a gradual dose reduction (GDR) for psychotropic medication for one resident. Observation showed the resident sleeping in bed during the day, and interview with a family member revealed concerns about the resident's medication regimen, specifically noting that the resident was sleeping during the day and awake at night. The family member was aware the resident was taking a sleeping pill but was unsure of the administration time. Record review indicated the resident had diagnoses including anxiety and traumatic brain injury and had an active order for Seroquel (Quetiapine Fumarate) 12.5 mg twice daily for psychosis manifested by agitation and aggression. Further review found that the facility was unable to provide monthly pharmacy medication reviews for three consecutive months, and there was no documentation of any gradual dose reduction attempts during that period. The facility's policies required GDRs for residents on psychotropic medications unless clinically contraindicated, and required documentation and action on pharmacy drug regimen review recommendations. The lack of GDR and missing documentation led to the resident potentially receiving unnecessary medication.