Failure to Document Non-Pharmacological Interventions for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to document non-pharmacological interventions (NPIs) for five residents who were prescribed psychotropic medications. For each of these residents, physician orders specified the use of medications such as alprazolam, bupropion, olanzapine, fluoxetine, escitalopram, lorazepam, quetiapine, divalproex sodium, and risperidone to manage conditions including anxiety, depression, schizophrenia, bipolar disorder, and schizoaffective disorder. Behavior Monitoring Records (BMRs) for these residents documented episodes of behaviors such as irritability, mood changes, sadness, delusions, anxiousness, agitation, angry outbursts, mood swings, and auditory hallucinations. However, the corresponding Non-Pharmacological Intervention (NPI) Flow Sheets for each resident were found to be blank for the relevant months, indicating that no NPIs were documented as provided during these behavioral episodes. Care plans for each resident included specific interventions requiring the use of non-drug approaches to address behaviors in addition to the ordered medications. These care plans also directed staff to document any non-drug interventions on the appropriate non-medication intervention sheets whenever resident behaviors occurred. Despite these documented care plan requirements, there was no evidence in the medical records that NPIs were implemented or recorded for any of the behavioral episodes noted in the BMRs for the sampled residents. During interviews and concurrent record reviews, the Director of Nursing (DON) and a Supervising Registered Nurse (SRN) acknowledged that the medical records did not show any NPIs provided as required by the care plans and facility policy. The facility's policy on psychotropic medication management also specified that behavioral interventions should be implemented and documented in an attempt to decrease target behaviors. The lack of documentation and apparent lack of implementation of NPIs for residents receiving psychotropic medications constituted the deficiency identified by surveyors.