Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that recommendations for gradual dose reductions (GDR) of psychotropic medications were followed for three residents. For one resident with vascular dementia and anxiety disorder, the consulting pharmacist recommended a GDR of escitalopram, which was accepted by the provider. The resident’s guardian was informed and objected to the reduction, but the medication was discontinued. Following the discontinuation, the resident exhibited increased behavioral symptoms, required additional medication for anxiety, and eventually had the escitalopram restarted after the guardian expressed distress over the discontinuation. Another resident with chronic obstructive pulmonary disease and Alzheimer's disease was due for a GDR of aripiprazole as recommended by the consulting pharmacist. The provider accepted the recommendation, but no new medication orders were written, and the resident continued to receive the original dose. Staff confirmed that the GDR was not implemented as recommended. A third resident with congestive heart failure and morbid obesity was also due for a GDR of bupropion, with the provider accepting the recommendation to discontinue the medication. However, no instructions were given to staff to discontinue the medication, and the resident continued to receive the same dose. Staff acknowledged that the order should have been clarified and acted upon. These failures were identified through observation, interview, and record review.