Inadequate Management of Psychotropic Medications
Penalty
Summary
The facility failed to manage and monitor medication regimens effectively for Resident 4, who was admitted with diagnoses including dementia with mood disturbances, anxiety, and a history of falling. The resident was severely cognitively impaired, as indicated by a BIMS score of 4. The care plan identified potential for distressed mood and behavioral symptoms, with interventions including medication per physician order and gradual dose reduction. However, a physician's order increased the dosage of Geodon, an antipsychotic medication, without documented behavioral evaluations, psychiatric reassessments, or non-pharmacological interventions. Additionally, there was no resident-specific rationale for the concurrent use of Geodon and Ativan, an antianxiety medication, nor was there documentation of gradual dose reduction or interdisciplinary team discussion. The deficiency was further evidenced by the resident experiencing three falls with injury, requiring emergency room visits, and the lack of documentation supporting the medication changes. An observation noted the resident sleeping in the activity room, while other residents participated in activities. The Director of Nursing confirmed the absence of resident-specific documentation to justify the increase in antipsychotic medication or the continued use of both psychoactive medications for Resident 4.