Delay in Implementing Psychotropic Medication Dose Reduction
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication underwent a timely gradual dose reduction as ordered by the physician. The resident, who had diagnoses of major depressive disorder and anxiety disorder, was prescribed haloperidol 1 mg at bedtime. On July 21, 2025, the physician agreed with the consultant pharmacist's recommendation to decrease the dose to 0.5 mg at bedtime and ordered monitoring for behavioral changes for 14 days following the change. However, the physician's order to decrease the dose was not promptly reflected in the resident's current medication orders. Despite the physician's order, the resident continued to receive haloperidol 1 mg at bedtime for 35 days after the dose reduction was approved. The medication administration record confirmed that the dose was not changed to 0.5 mg until August 28, 2025. The facility's policy did not specify a timeframe for acting on physician orders, and the delay was identified by the consultant pharmacist and brought to the attention of nursing staff. The Nursing Home Administrator acknowledged that physician orders should be acted upon in a timely manner.