Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, Resident R23, who was diagnosed with multiple sclerosis, dementia without behaviors, and anxiety, was administered Seroquel, an antipsychotic medication, for anxiety. The facility's policy on psychotropic medication use states that residents should not receive medications that are not clinically indicated to treat a specific condition. However, a review of Resident R23's progress notes and behavior monitoring documentation from July 2024 through January 2025 showed no documentation of unwanted behaviors that would justify the use of such medication. The deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs without adequate indications for use. This oversight was identified for one of five residents reviewed, highlighting a lapse in adherence to the facility's medication policy and federal regulations regarding the use of psychotropic drugs.
Plan Of Correction
1. Resident R23 has a correct diagnosis for Seroquel and the care plan has been updated and behavior monitoring is in place. 2. Current residents on antipsychotics will be reviewed to ensure the medications have the correct diagnosis, the care plan is updated, and behavior monitoring is in place. 3. The DON or designee will in service the licensed staff on correct diagnoses for antipsychotics, updating the care plans and implementing behavior charting. 4. The DON or designee will review new orders for antipsychotics medications during the clinical meeting to ensure antipsychotic medications have the correct diagnosis, the care plan is updated and behavior monitoring is in place weekly x4 weeks. The QAPI committee will determine the need for further audits.