Failure to Ensure Gradual Dose Reduction and Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents did not receive unnecessary psychotropic medications and that adequate monitoring was in place for those receiving such medications. For one resident with diagnoses including dementia, insomnia, and major depressive disorder, there was no evidence of depressive symptoms since admission, as indicated by repeated PHQ-9 scores of zero. Despite this, the resident continued to receive escitalopram, oxcarbazepine, and trazodone at the same dosages without any documented attempt at gradual dose reduction (GDR) or clinical rationale for not attempting a GDR, even after a pharmacist recommended a dose reduction. The provider declined the recommendation without providing a clinical justification, and the medical record lacked documentation supporting the continued use of these medications at their current dosages. Additionally, the facility did not adequately monitor for adverse side effects or follow black box warning requirements for residents on antidepressant medications. Staff interviews revealed that nurses were not monitoring for suicidal thoughts, behaviors, or worsening depression symptoms, despite black box warnings attached to the orders for escitalopram and trazodone. Staff acknowledged these warnings in the electronic medical record but were not instructed on appropriate actions to take, and there was no documentation that providers were notified of the warnings or that residents were being monitored as required. A second resident with multiple psychiatric and neurocognitive diagnoses was prescribed duloxetine, which also carries a black box warning for monitoring suicidal thoughts and behaviors. However, there was no documentation in the medical record that this resident was being monitored for these symptoms. Nursing staff confirmed that unless the medication administration record (MAR) specifically instructed them to monitor for suicidal ideation, such monitoring and documentation did not occur. The DON confirmed the absence of monitoring and documentation for suicidal ideations, despite the presence of black box warnings and the expectation that staff would assess and communicate with providers as needed.