Failure to Prevent Unnecessary Use of Psychotropic Medications and Chemical Restraints
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure that three of five sampled residents were free from chemical restraints. For one resident, Quetiapine (Seroquel) was administered without proper monitoring of target behaviors, without clinical documentation supporting a diagnosis of schizophrenia, and without evidence that nonpharmacological interventions (NPI) were attempted or provided. Interviews with facility staff and a psychiatrist revealed that the resident did not exhibit hallucinations or delusions, and there was no clear documentation of schizophrenia in the clinical record. Nursing progress notes and medication administration records showed zero episodes of the target behavior, and staff acknowledged that NPI interventions were not documented or implemented prior to or during the use of the antipsychotic medication. Another resident continued to receive Risperidone (Risperdal) for a diagnosis of bipolar disorder manifested by hitting staff during care, but there was no documentation of NPI interventions attempted or provided. Staff interviews indicated that the resident was generally calm, did not display physical aggression, and responded well to familiar caregivers. Review of the resident's care plan and medication records confirmed the absence of NPI monitoring or documentation, and staff stated that such interventions should have been implemented to address the resident's behaviors. A third resident was prescribed Olanzapine for psychosis manifested by striking out during care, but the facility failed to monitor the resident's behavior as required by the care plan and physician's order. The medication administration record only indicated yes/no responses for suicidal ideation without quantifying the frequency of behaviors, making it difficult to assess the effectiveness of the medication or the need for dose adjustments. The facility's policies required monitoring and documentation of behaviors and the use of nonpharmacological interventions, but these were not followed for the residents in question.