Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication was provided with a gradual dose reduction (GDR) and behavioral interventions, unless clinically contraindicated, as required. A resident with diagnoses including schizoaffective disorder, bipolar type, and depression was observed sleeping in bed during multiple observations. The resident had physician's orders for clozapine at two different dosages for schizoaffective disorder, bipolar type, since March 2023. Review of the medical record did not reveal documentation of a clinical contraindication to GDR, nor evidence that a GDR had been attempted for this medication. The Director of Nursing confirmed that while psychotropic medication reviews occurred at least quarterly and GDRs were discussed in monthly meetings, there was no record of a GDR attempt for this resident.