Failure to Ensure Unnecessary Psychotropic Drug Use Was Prevented
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use. A resident with dementia was prescribed quetiapine, an antipsychotic medication, which was increased from 12.5 mg to 25 mg at bedtime despite no documented behavioral changes or rationale for the increase. Staff documentation and behavior monitoring forms showed no evidence of confusion or agitation from the time of the dose increase through the present. The neurologist's consultation and subsequent medication order did not include documentation of behaviors warranting the dose increase, and the facility's monitoring process did not prompt a review or discussion regarding the absence of behaviors. Interviews with nursing staff, the consultant pharmacist, and the Director of Nursing revealed a lack of awareness and action regarding the requirement for a gradual dose reduction (GDR) for psychotropic medications. The consultant pharmacist continued to document the same assessment and plan for the medication each month, without addressing the absence of behaviors or the need for a GDR. The facility did not have a policy specific to GDR for psychotropic medications, and staff did not provide a rationale for not attempting a dose reduction, despite regular interdisciplinary team meetings to discuss psychotropic medication use.