Inadequate Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had adequate indications for their use, as evidenced by the cases of two residents. Resident R35 was admitted with diagnoses of dementia, anxiety, and depression, but was prescribed Haloperidol Lactate for schizophrenia, a condition not documented in her clinical record. This discrepancy was confirmed by the Vice President of Clinical Services, indicating a failure to maintain a medication regime free from potentially unnecessary medications. Similarly, Resident R43, who was diagnosed with schizophrenia, seizure disorder, and anemia, was prescribed Risperdal, an antipsychotic medication, for depression. However, there was no appropriate indication for use diagnosis in the physician order for this medication. This was confirmed by the RN Supervisor and the Director of Nursing, highlighting the facility's failure to ensure adequate indication for psychotropic medication use for these residents.
Plan Of Correction
Resident #35's Haldol orders were updated with the correct indication for use by the DON/Designee. Resident #43's order for Risperdal was updated to include the correct indication for use by the DON/Designee. All residents receiving antipsychotics have the potential to be affected. The DON/Designee will audit all current residents on antipsychotics to ensure the medication orders have the correct indication for use. The DON/Designee will educate licensed nurses on the facility policy for antipsychotic medication use. The DON/Designee will audit new antipsychotic orders 2x per week x 4 weeks to ensure orders include the correct indication for use. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.