Failure to Document Specific Conditions for Psychotropic Medications
Penalty
Summary
The facility failed to dispose of or reconcile discontinued medications in a timely manner in the Third Floor Medication Room, as confirmed by Employee E5. This action is in violation of the Pennsylvania Code 211.12 (d)(3)(5) regarding nursing services and 211.9 (a)(1)(j.1)(k) concerning pharmacy services. Additionally, the facility did not meet the requirements outlined in §483.45(e) regarding the administration of psychotropic drugs. Specifically, the facility did not identify a diagnosed specific condition for the treatment of a resident receiving psychotropic medications, which is a requirement under §483.45(e)(1)-(5). Resident R62, who was admitted to the facility on 9/1/21, was receiving psychotropic medications without a documented specific condition for treatment. The resident's clinical record indicated diagnoses of high blood pressure, hyperlipidemia, and dementia. However, physician orders for Seroquel and trazodone, dated 11/14/24 and 11/24/24 respectively, did not specify a condition for their use. The Director of Nursing confirmed the facility's failure to document a diagnosed specific condition for the psychotropic medication usage for Resident R62, as required by the facility's policy and regulatory standards.
Plan Of Correction
Resident #62 no longer resides at the facility. To identify other residents that have the potential to be affected, the DON/designee reviewed current residents on psychotropic medications to ensure resident medication regimens are free from unnecessary medications and that there is a diagnosed specific condition for treatment. Corrections will be made as needed. To prevent this from recurring, the RDCS/designee educated DON, ADON and pharmacy consultant on the regulatory requirements of F758 on ensuring resident medication regimens are free from unnecessary medications, and that there is a diagnosed specific condition for treatment. To monitor and maintain ongoing compliance, the DON/designee will review the medical record of 3 residents on psychotropic medications weekly x4 then monthly x2 to ensure that there is a diagnosed specific condition for treatment regarding medication. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.