Failure to Document Justification for Antipsychotic Use and GDR
Penalty
Summary
The facility failed to document an appropriate diagnosis and identify target behaviors to justify the use of an antipsychotic medication for a resident. The resident, who had a diagnosis of vascular dementia with behavioral disturbance, was prescribed Risperidone 0.25 mg at bedtime. The care plan and physician orders referenced the use of Risperidone for behavioral symptoms, but there was no clear documentation of specific target behaviors warranting the medication. Staff interviews confirmed that the resident did not display behaviors such as aggression or harm to self or others, and behavior tracking indicated only two verbal behaviors in the past six months, both occurring before January. The resident's behaviors reportedly improved after moving to a private room, and no recent behaviors were documented that would support ongoing antipsychotic use. Additionally, the facility did not provide appropriate justification for a failed gradual dose reduction (GDR) of Risperidone. The medication was discontinued, but was restarted three days later due to symptoms of insomnia and tearfulness, as documented by the nurse practitioner. However, there was no evidence of a thorough assessment or documentation of behaviors that would necessitate resuming the antipsychotic. The facility's policy requires clear documentation of behaviors, rationale for medication use, and substantiation for unsuccessful GDRs, which was not met in this case.