Failure to Ensure Appropriate Use and Monitoring of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication, specifically Xanax, was appropriate to treat a specific and documented condition in accordance with facility policy. The resident, who had diagnoses including dementia, Alzheimer's disease, depression, schizophrenia, and anxiety, had a physician's order for Xanax to be administered daily for anxiety as manifested by constant restlessness and repetitive physical movement. However, there was no documented evidence in the Medication Administration Record or Treatment Administration Record that the resident was monitored for these symptoms as required for the use of Xanax. Observations showed the resident was frequently sleeping, and staff interviews revealed inconsistencies and lack of clarity regarding the presence or nature of the resident's repetitive movements. Some staff described the movement as scratching, while others stated there were no repetitive movements. Nursing staff, including LVNs and RNs, were unable to specify or monitor the symptoms as indicated in the medication order, and the DON acknowledged the need for clarification. The facility's policy required psychotropic medications to be used only for specific, diagnosed, and documented conditions, with monitoring and documentation of the resident's response, which was not followed in this case.