Failure to Ensure Drug Regimen Free from Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of Seroquel, an antipsychotic medication. The clinical records did not contain a documented assessment to support the diagnosis of bipolar disorder, which was listed as the indication for Seroquel use. Review of the resident’s hospital and facility records showed that the original order for Seroquel was for acute agitation/delirium, but upon admission to the facility, the medication was continued for bipolar disorder without supporting documentation or evidence of such a diagnosis. The facility’s Minimum Data Set and psychiatric evaluation did not indicate the presence of behaviors or symptoms consistent with bipolar disorder or psychosis during the relevant period. Further review of the resident’s Medication Administration Record and behavior monitoring logs revealed that there were no documented episodes of the behaviors that would warrant the use of Seroquel for bipolar disorder. Interviews with therapy staff and the Director of Rehabilitation indicated that the resident initially was able to follow commands and participate in therapy, but later became lethargic and confused, which interfered with rehabilitation. Family members and staff expressed concerns that the resident was overmedicated, leading to increased sleepiness and decreased participation in therapy. The medical doctor confirmed that there was no diagnosis of bipolar disorder in the resident’s records and stated that he continued the Seroquel order from the hospital without verifying the indication. The facility’s policy required that psychotropic medications be used only with a clear clinical indication and after ruling out other causes for behaviors, but this was not followed in the resident’s case. The lack of proper assessment, documentation, and monitoring led to the resident receiving an antipsychotic medication without adequate justification.