Failure to Ensure Proper Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from potentially unnecessary psychotropic medications, as evidenced by the cases of three residents. Resident 69 was prescribed Ativan for anxiety, with an order allowing administration every six hours as needed. However, there was no documented rationale from the physician for the continued use of Ativan beyond the 14-day limit, as required by regulations. The medication was only discontinued after surveyors questioned the order. Similarly, Resident 77 was also prescribed Ativan with a similar order, but again, there was no documented rationale for its continued use beyond 14 days. The medication was discontinued nearly six months after it was initially prescribed, following the surveyors' review. This indicates a pattern of non-compliance with the requirement to document the necessity of continued psychotropic medication use. Resident 85's case involved a medication error where the resident received double doses of Lorazepam due to a transcription issue and confusion with the medication card from the pharmacy. The resident, who had a severe cognitive impairment, was noted to be excessively sleeping, and the family expressed concerns about lethargy. Despite staff awareness of the error, there was no documentation of an investigation or corrective action taken to address the medication error during the specified dates.
Plan Of Correction
The orders for residents 69 and 77 were discontinued. The order for resident 85 was corrected on 1/6/25. An audit of prn psychotropic medications for current residents was completed to ensure that each order included a 14 day stop. An audit of current residents with orders for psychotropic medications was completed to ensure the delivered medication matches the physician's order. Education will be provided to all licensed nurses to ensure orders received for prn-psychotropic medications include a 14 day stop, and to identify and report any discrepancies with delivered medications and physician orders for administration. The DON or designee will complete audits of new psychotropic medication orders to ensure that prn medications include a 14 day stop and that delivered medications match physician orders x8 weeks. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.