Unnecessary Psychotropic Medication Prescribed Without Adequate Indication
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following a stroke, and dementia was prescribed lorazepam, an antianxiety medication, twice daily for behaviors associated with dementia, such as yelling and removing clothes. The medication order was documented without an adequate clinical indication, as dementia is not an approved diagnosis for lorazepam use. The resident's medication regimen also included other psychotropic and sedative medications, such as Seroquel XR, melatonin, gabapentin, and fluoxetine. A review by the consultant pharmacist identified that lorazepam was being prescribed for an unapproved diagnosis and recommended a re-evaluation of the order or a rationale to support its use. The attending physician's response did not provide a rationale for the continued order. The facility's policy on psychotropic medication use requires a documented clinical indication in line with accepted clinical standards, which was not met in this case.