Inadequate Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication had an adequate indication for its use. Specifically, Resident R108 was prescribed quetiapine, an antipsychotic medication, for anxiety without an appropriate diagnosis documented in the clinical record. This was identified during a review of the facility's policy on medication and treatment orders, which requires that medication orders include the clinical condition for which the medication is prescribed. Resident R108 was admitted to the facility with diagnoses including atrial fibrillation, heart failure, high blood pressure, and anxiety disorder. Despite these conditions, the facility did not provide a documented diagnosis justifying the use of quetiapine for anxiety. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the lack of an appropriate diagnosis for the use of the antipsychotic medication in this case.
Plan Of Correction
Resident R108 remains at the facility with no adverse outcomes. All residents receiving psychotropic medications will be audited to ensure residents have proper clinically indicated diagnosis for use. All licensed nursing staff will be educated on the clinically indicated use of psychotropics including proper diagnosis for use. The DON or designee will audit all psychotropics being used in the facility for proper diagnosis. Audits will be completed weekly x8. All results to be reviewed through QAPI for further recommendation.