Failure to Document and Attempt Non-Pharmacological Interventions Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and that behavioral indications were present and documented prior to administering psychotropic medications for two residents. For one resident with dementia and anxiety disorder, records showed that medications such as Ativan and Seroquel were administered without prior documentation of non-pharmacological interventions or consistent behavioral indications. The resident's Medication Administration Records (MARs) indicated frequent administration of these medications even when there were few or no documented episodes of the behaviors they were intended to treat. Interviews with nursing staff and the Assistant Director of Nursing (ADON) confirmed that non-pharmacological interventions were not documented or attempted prior to medication administration, and that increases in medication dosage were based on verbal reports rather than verified behavioral documentation. For another resident with anxiety, depression, insomnia, and paraplegia, clonazepam was administered three times daily for anxiety manifested by "multiple concerns." However, the MARs and order summaries lacked specific documentation of the behavioral manifestations being monitored. Staff interviews revealed that the orders did not specify exact behaviors, and the lack of specificity in documentation and monitoring placed the resident at risk for prolonged and potentially unnecessary use of psychotropic medication. The Director of Nursing (DON) acknowledged that the absence of clear behavioral indications and monitoring could lead to inappropriate care planning and medication use. The facility's own policy required that psychotropic medications only be used when necessary to treat specifically diagnosed conditions, with clear documentation of symptoms and attempted non-pharmacological interventions. Despite this, the records and staff interviews demonstrated that these steps were not consistently followed for the two residents, resulting in the administration and escalation of psychotropic medications without adequate justification or documentation.