Psychotropic Medication Orders Lacked Indication for Use
Penalty
Summary
The facility failed to ensure that psychotropic medication orders included an indication for use for one resident. Record review showed that a cognitively intact resident with multiple diagnoses, including depression, anxiety, polyneuropathy, hypertension, and amputation, had active orders for duloxetine and pristiq without any listed indication for use. During interviews, both a registered nurse and the director of nursing confirmed that these medication orders lacked an indication, which was contrary to facility policy requiring every medication order to have an associated indication or diagnosis. The facility's medication administration policy also specified that staff should be able to state the indication for each medication administered.