Inadequate Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper management and monitoring of medication regimens for a resident, identified as Resident A16, who was admitted with vascular dementia with mood disturbances. The resident was prescribed multiple psychotropic medications, including Ativan, Seroquel, and Trazodone, without adequate documentation of a specific medical diagnosis justifying their use. The clinical record review revealed that the attending physician's documentation did not meet the criteria for the use of these psychoactive medications, as there was no resident-specific rationale provided for their continued use. During the survey, it was confirmed by the Director of Nursing that the physician documentation lacked accurate resident-specific details to support the use of the psychoactive medications. This deficiency was identified through clinical record review and staff interviews, indicating a failure to promote or maintain the resident's highest practicable well-being in relation to the use of psychoactive medications.
Plan Of Correction
- A16 reviewed by physician to complete appropriate documentation for use of the PRN medication. - A house audit completed on current residents related to psychotropic medications/PRN use to determine any irregularities. - Policy entitled, Medication Utilization and Prescribing - Clinical Protocol reviewed and education provided to licensed staff, social service, and attending physician. - DON or designee will conduct weekly audits x 4, then monthly x 2 for psychotropic medication/PRN usage and appropriate documentation for the use of medication. - Audits will be presented at the monthly QAPI committee for ongoing oversight.