Failure to Document Non-Pharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraints and that psychotropic medications were used appropriately. For one resident with diagnoses including chronic subdural hemorrhage, dementia, and anxiety disorder, lorazepam and trazodone were administered for anxiety and depression without any clinical documentation that non-pharmacological interventions were attempted or provided. Nursing progress notes and medication administration records over several months did not indicate any such interventions, and the DON confirmed the absence of this documentation. Another resident with type 2 diabetes, dementia, and depression continued to receive mirtazapine and sertraline for depression, again without documentation of non-pharmacological interventions being attempted or provided. Review of nursing progress notes and medication administration records for multiple months confirmed this lack of documentation, which was also acknowledged by the DON. The facility's own policy required the use of behavioral interventions unless contraindicated and proper documentation of the clinical need for psychotropic medications. A third resident, diagnosed with Alzheimer's disease, was prescribed quetiapine for psychosis manifested by paranoia. However, there was no monitoring of the target behavior for which the medication was prescribed. The DON confirmed that behavior monitoring should have been in place for this medication, and the facility's policy required ongoing evaluation of the effectiveness of psychotropic medications and assessment for adverse consequences, including periodic reevaluation of behavioral symptoms.