Failure to Manage Psychotropic Medications and Documentation
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The clinical record review revealed that a resident with diagnoses of hypertension and bipolar disorder was prescribed clonazepam and lorazepam, both benzodiazepines, for anxiety and restlessness. These medications were continuously reordered without documented clinical rationale for their duplicative use, despite a pharmacy recommendation to consolidate the medications. The provider disagreed with the recommendation, citing perceived benefits over risks, but no documented review of the risks and benefits was found. Additionally, the facility did not adhere to the prescribed administration schedule for lorazepam. The Controlled Drug Record showed instances where lorazepam was administered less than six hours apart, contrary to the physician's orders. Furthermore, there were discrepancies between the Controlled Drug Record and the electronic Medication Administration Record (MAR), with numerous administrations not recorded in the MAR. The facility also administered lorazepam to the resident during a period when there was no active physician order for the medication. This occurred on multiple occasions, indicating a failure to ensure that medications were only administered with a valid physician order. The Director of Nursing confirmed that it was the facility's expectation for staff to follow prescribed time frames and document all medication administrations accurately.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R26. 2) The Facility reviewed R26, but resident has since discharged and no longer resides at the facility. 3) All current residents were reviewed for duplicate therapy and Physician documentation for Risk/Benefit and orders and signed Physician orders. 4) All current residents were reviewed for Medication Administration and Controlled drug record for correct administration times frames as prescribed and for missing documentation. Two: system changes and measures that will be taken: 1) All Licensed staff and Medical Director and Medical Providers will be in-serviced on documentation Psychotropic drug use, Duplicate Therapy, correct administration times frames as prescribed and for missing documentation. 2) Documentation will be monitored at Daily Clinical meetings for accuracy. 3) Pharmacy Consultant to review for accuracy and discrepancies. 4) Medical Director and his staff will be in-serviced on documentation for Risk/Benefits of use. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with Psychotropic drug use, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.