Failure to Act on Pharmacist’s Gradual Dose Reduction Recommendation for Antidepressant
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of pharmacy consultant recommendations for gradual dose reduction (GDR) of psychotropic medications. The consultant pharmacist completed a monthly drug regimen review on 08/29/25 and documented a GDR request for a resident’s amitriptyline 100 mg daily, noting that per CMS regulations residents on psychotropic drugs must have GDR attempts unless clinically contraindicated. Record review showed the resident, an adult male with a diagnosis of depression and an intact BIMS score of 15, had been admitted earlier in the year and was receiving amitriptyline for major depressive disorder. His MDS and care plan documented ongoing antidepressant therapy and monitoring for depressive symptoms and adverse reactions. Medication administration records for November and December 2025 showed he continued to receive amitriptyline daily as originally ordered. Interviews and record review revealed that the pharmacy consultant’s August 2025 GDR recommendation for this resident’s antidepressant was not communicated to the attending physician and no action was taken. The ADON, who was responsible for reviewing pharmacy recommendations, acknowledged that the August GDR recommendation for the resident’s antidepressant was missed and was not forwarded to the physician. The DON confirmed that the ADON was responsible for reviewing pharmacy recommendations and stated she was unaware that this GDR recommendation had been missed. The facility’s psychotropic drugs policy, dated 10/25/17, stated that the facility implements GDRs and non-pharmacological interventions, unless contraindicated, for psychotropic medications. Despite this policy and the pharmacist’s documented recommendation, the resident’s drug regimen was not adjusted or reviewed with the physician in response to the GDR request.
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