Failure to Ensure Proper Indication and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not providing a proper clinical indication for the use of an anti-anxiety medication. The resident, who had diagnoses of Anxiety Disorder and Major Depressive Disorder, was receiving alprazolam (Xanax) on a routine basis for anxiety. The physician's order and care plan both cited 'feeling of impending danger' as the indication for use, but interviews with staff revealed that this was not an accurate description of the resident's symptoms, which included panic attacks and increased heart rate, particularly when discussing family issues. Staff also noted that behavior monitoring for the medication was not accurately capturing the resident's actual symptoms, and that the information provided to the physician regarding the resident's progress was inadequate. The resident was cognitively intact and able to communicate her symptoms, yet the documentation and monitoring did not align with her reported experiences. The facility's policy required adequate monitoring for efficacy and adverse consequences, as well as a documented clinical rationale for psychotropic medication use based on assessment of the resident's condition. However, the lack of accurate behavior monitoring and documentation meant that the continued use of alprazolam was not properly justified according to the facility's own policy and regulatory requirements.