Inadequate Medication Indication and Monitoring
Penalty
Summary
The facility failed to ensure that medications were administered with adequate indications for use and monitoring for two residents. For Resident R46, the clinical record showed that the resident was prescribed Melatonin and Trazodone for insomnia, despite not having a diagnosis of insomnia. This indicates a lack of adequate indication for the use of these medications. For Resident R83, the facility did not document the rationale for the continued use of Lorazepam beyond 14 days, as required for psychotropic medications. Additionally, the resident was prescribed Depakote without adequate indication for its use, as the medication is typically used for bipolar disorder, epilepsy, or migraines, none of which were documented as diagnoses for the resident. Furthermore, a blood level test for Depakote showed a below-normal range, but there was no documentation that this was reviewed with the physician to ensure proper monitoring.
Plan Of Correction
1. On 12/19/24 the DON assessed Resident R46 and Resident R83 and there were no negative outcomes. 2. On 12/20/2024 the DON obtained an order and added the insomnia diagnosis for Resident R46. On 1/5/2025 he attending physician discontinued the order for Lorazepam for Resident R83. 3. On 12/26/24 the nurse managers reviewed the electronic health records for residents with a PRN order for a psychotropic medication to verify that documentation indicating continued use past 14 days is present. 4. During the morning clinical meeting the IDT team will review new and existing PRN orders for psychotropic medications to verify diagnosis and supporting documentation by the physician for continued use. 5. Education on administering medications with the proper diagnosis and physician documentation for continued psychotropic medications will be presented by the DON/designee to licensed nurses by 1/16/2025. 6. The DON/designee will conduct audits on administering medications with proper diagnosis and documentation for continued use and monitoring weekly for 4 weeks and monthly for 3 months.