Failure to Ensure Appropriate Use and Documentation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were only used when medically indicated and that appropriate documentation and non-pharmacological interventions were in place for three residents. For one resident with depression and metabolic encephalopathy, multiple psychotropic medications were administered without supporting diagnoses or care plan interventions, and the pharmacy had raised concerns about the lack of justification for these medications. The social worker confirmed that there were no known medical conditions to justify the use of these medications and that this issue should have been addressed prior to admission. Another resident, admitted with spinal stenosis and a history of falls, was prescribed antipsychotic and antidepressant medications following a hospital stay for delirium. However, there was no documentation of a diagnosis supporting the continued use of these medications, and consent for the antidepressant was not obtained as required. Both the director of nursing and the pharmacist acknowledged that delirium is a symptom rather than a diagnosis and that the necessary documentation and non-pharmacological interventions were missing. Behavior monitoring logs and medication administration records showed no documented behaviors to justify the ongoing use of these medications. A third resident with severe cognitive impairment and diagnoses of dementia, mood disturbance, and anxiety was prescribed an antimanic medication. The care plan did not include any non-pharmacological interventions, and progress notes described behavioral issues without listing alternative approaches. The director of nursing stated that monitoring for adverse side effects should be done per shift, but the facility's policy required that psychotropic medications only be initiated after non-pharmacological interventions had been attempted, which was not followed in these cases.