Failure to Ensure Drug Regimens Are Free from Unnecessary Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' drug regimens were free from unnecessary medications for three out of five residents reviewed. Specifically, residents were prescribed sleep medications such as melatonin and trazodone without adequate clinical indications, assessments, or care plans addressing sleep management. There was no documentation of sleep assessments, monitoring of sleep patterns, or tracking of sleep quality to justify the continued use of these medications. The care plans for these residents did not include individualized interventions or non-pharmacological approaches to promote sleep, as required by facility policy. One resident was also found to be receiving a daily antibiotic for urinary tract infection (UTI) prevention without documented rationale or evidence supporting the need for prophylactic antibiotic use. The infection preventionist and nursing staff were unable to provide criteria or justification for the ongoing antibiotic therapy, and there was no documentation of recurrent UTIs or physician rationale for this regimen. Staff interviews revealed a lack of understanding regarding the appropriateness of the medication orders and an absence of oversight or challenge to the prescriber's decisions. The facility's policy requires comprehensive assessment and individualized care planning for behavioral and psychosocial symptoms, including sleep disturbances. However, the survey found that these processes were not followed. There was no evidence of behavioral assessments, cause identification, or targeted interventions for the affected residents. Staff interviews confirmed that sleep was not routinely monitored or documented, and care plans did not address sleep issues or include non-pharmacological interventions, resulting in the continued use of unnecessary medications.