Failure to Ensure Appropriate Use and Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had appropriate diagnoses and that proper justification was provided for not attempting gradual dose reductions. For one resident, olanzapine, an antipsychotic medication, was ordered for anxiety upon admission without a documented psychiatric diagnosis. The DON and ADON confirmed that the medication was continued from the hospital without an appropriate diagnosis, and there was no documentation to justify its use. Facility policy required that the prescribing practitioner and interdisciplinary team determine if continuing such medication was justified when no clear indication was present, but this was not followed. For another resident, multiple psychotropic medications were prescribed, including hydroxyzine, trazodone, and buspirone. Pharmacy recommendations to gradually reduce the dose of hydroxyzine were made on two occasions, but the provider denied these requests, citing reasons such as scheduled surgery and shoulder pain. There was no evidence that further attempts at gradual dose reduction were made, nor was there documentation of clinical contraindication as required by facility policy. The facility's failure to ensure appropriate diagnoses and to attempt or justify not attempting gradual dose reductions for psychotropic medications resulted in noncompliance with their own policies.