Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medication. Resident 101 was admitted on March 14, 2025, with an active physician order for Lunesta, a sedative hypnotic medication, to be administered at bedtime. The admission Minimum Data Set (MDS) completed on March 19, 2025, indicated that the resident was receiving a hypnotic medication, and the facility planned to develop a care plan for the psychotropic medication use. However, upon review, it was found that the care plans for Resident 101 did not include the use of a sedative hypnotic for sleep, nor did they include non-pharmacological interventions or identify target behaviors to support the continued use of the medication. Interviews with the Nursing Home Administrator, Director of Nursing, and an assistant director of nursing confirmed that there was no plan of care or monitoring of target behaviors for the resident's use of the sedative hypnotic.
Plan Of Correction
Resident 101 is no longer a resident of the facility. A baseline audit of residents utilizing psychotropic medications will be reviewed to ensure that care plans are in place to address target behaviors and non-pharmacological interventions. Nursing staff, Social Service, and Assessment Nurses will be educated on the implementation of care plans for residents utilizing psychotropic medications. An audit of residents with new orders for psychotropic medications will be reviewed to ensure the appropriate care plan is in place weekly for 4 weeks. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.