Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraint
Penalty
Summary
Two residents were not protected from unnecessary psychotropic medication use, resulting in chemical restraint. One resident was administered Seroquel daily for psychosis, despite lacking a diagnosis of schizophrenia, depression, or bipolar disorder, which are the only acceptable indications for this medication in elderly patients. The resident's records, including the face sheet, care plan, and Minimum Data Set, did not support the use of Seroquel, and a Preadmission Screening and Resident Review confirmed the absence of a serious mental illness. The medication was continued after hospital readmission without proper verification, and the facility's own policies required antipsychotic medications to be used only when necessary for specific, documented conditions. A pharmacy recommendation to discontinue Seroquel due to lack of appropriate diagnosis was not followed up in a timely manner. The recommendation was not signed or dated by the attending physician, and there was no documentation of agreement or alternative action. Additionally, a psychiatrist consultation, as noted in the physician's progress notes, was not initiated after the resident's readmission, and the resident was not included on the list for psychiatric evaluation. Facility staff interviews confirmed that the necessary follow-up actions were not taken, and the resident continued to receive Seroquel unnecessarily. Another resident was prescribed Remeron for depression manifested by poor appetite, but there were no orders for monitoring the specific behavior (poor appetite) or for monitoring potential side effects of the medication. Nursing staff acknowledged missing the required monitoring orders, and the DON confirmed that such monitoring is necessary to determine the effectiveness of the medication and to identify any adverse effects. Facility policies required that psychotropic medications be supported by documented rationale, administered at correct doses and duration, and with adequate monitoring, which was not done in this case.