Failure to Document Specific Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were prescribed for specific diagnoses for two residents. Resident 82, who had diagnoses including Alzheimer's disease, anxiety, and stroke, was prescribed the antipsychotic medication Seroquel for agitation without evidence supporting its use for a specific diagnosis. This lack of documentation indicates a failure to comply with the requirement that psychotropic drugs be used only when necessary to treat a specific condition as diagnosed and documented in the clinical record. Similarly, Resident 116, with diagnoses of PTSD and depression, was prescribed antipsychotic medications haloperidol and quetiapine for psychosis. However, there was no evidence to support that these medications were used to treat a specific diagnosis. The Director of Nursing confirmed that the antipsychotic medication orders should have included specific diagnoses, highlighting a deficiency in the facility's adherence to regulatory requirements for psychotropic drug prescriptions.
Plan Of Correction
1. The psychotropic medication orders for Residents 82 and 116 were reviewed by the provider for proper diagnosis. 2. Current residents receiving antipsychotic medications was conducted to verify the medications were prescribed for a specific diagnosis. Residents with new orders for anti-psychotic medications will be reviewed during clinical meeting to verify that the medication was prescribed for a specific diagnosis. 3. NPE or designee will re-inservice licensed nursing staff on ensuring that psychotropic medications have specific diagnosis for administration and usage. 4. DON and/or designee will conduct audits weekly x 8, then monthly x 2 for residents with antipsychotic medications to verify a proper diagnosis has been ordered. Results of the audits will be presented at the QAPI committee for review and/or recommendations.