Failure to Manage Psychotropic Medications Appropriately
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications for two residents. Resident 9 was admitted on January 16, 2023, and was receiving Buspar and Cymbalta. A consultant pharmacist recommended a dose reduction of Cymbalta from 90 mg to 60 mg on July 13, 2024, which the physician agreed to on July 24, 2024. However, the facility did not implement this change until January 17, 2025, as confirmed by the Nursing Home Administrator and Director of Nursing. Resident 65 had multiple PRN orders for Ativan, a psychotropic medication, without appropriate stop dates or evaluations by a physician to justify the extensions beyond 14 days. The facility's documentation lacked evidence of non-medicinal interventions before administering the PRN Ativan. The consultant pharmacist recommended evaluating the necessity of the PRN Ativan, but the facility's physician and contracted physician's assistant opted to continue the medication with a 90-day stop date due to ongoing anxiety, without proper documentation of behaviors or provider evaluations to justify this decision. The facility's failure to adhere to regulatory requirements for psychotropic medications resulted in deficiencies related to unnecessary drug use. The surveyor confirmed these findings with the Nursing Home Administrator and Director of Nursing, highlighting the lack of compliance with medication management protocols and the absence of necessary documentation to support the continued use of psychotropic medications for Resident 65.
Plan Of Correction
• Cited: Resident 9 and resident 65 medication regime was reviewed and properly addressed by the physician. • Like: The facility will complete a medication regime review for current residents to ensure they are free for unnecessary medications directly related to physician recommendation to decrease Cymbalta and review of PRN antianxiety medication without supporting documentation. • Education: DON/designee will educate nursing staff to ensure the pharmacist and resident 39's recommendations are followed to avoid unnecessary medications as well as recommendation to decrease Cymbalta and review of PRN anti-anxiety medications without supporting documentation. • Audits: DON/designee will audit 5 random residents weekly x 4 weeks then monthly x 2 months to ensure the pharmacist resident 39's recommendations are followed to avoid unnecessary medications. Audit will also include recommendation to decrease Cymbalta and review of PRN anti-anxiety medications without supporting documentation. Results will be taken through QAPI.