Failure to Document Rationale for Psychotropic Medication Change
Penalty
Summary
The facility failed to ensure that psychotropic medication changes met professional standards of practice for a resident. Resident R158, who was admitted with diagnoses including non-traumatic brain dysfunction, delirium, and encephalopathy, was prescribed olanzapine for delirium. This medication was administered from the time of admission until a psychiatric evaluation on January 8, 2025, recommended discontinuing olanzapine and starting Depakote. However, the psychiatric consultant did not document a clinical indication or rationale for this medication change. Further review of the resident's progress notes revealed no documented changes in behavior prior to the psychiatric evaluation. Despite this, the resident began receiving Depakote the day after the evaluation, with the medication records indicating it was needed for a cognitive communication deficit. An interview with the Assistant Director of Nursing confirmed the absence of documented rationale or clinical indication for the medication change, highlighting a failure to meet professional standards of quality in the management of psychotropic medications for the resident.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R158 was seen by the psychiatrist. The reason for the medication change was documented in the Psychiatry progress note. The DON/designee audited the last 2 weeks of psychiatry recommendations to ensure if a medication change was made there is documentation indicating the reason for the medication change. The DON/designee educated the consultant psychiatrist on documenting reasons for medication changes on the consultant form. The DON/designee will audit psychiatry recommendations to ensure if a medication change was made there is documentation indicating the reason for the medication change. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.