Lack of Clinical Justification for Psychotropic Medication Increase
Penalty
Summary
The facility failed to provide clinical rationale or physician documentation justifying the increase in dosage of a psychotropic medication for a resident diagnosed with multiple psychiatric conditions, including depression, schizoaffective disorder/bipolar type, major depressive disorder, alcoholism-dependence/withdrawal, and anxiety disorder. The resident was cognitively intact, as indicated by a BIMS score of 15. The physician order sheet documented an increase in Venlafaxine HCL ER from 225 mg to 300 mg daily, but there was no corresponding progress note or documentation from the interdisciplinary team (IDT) or physician explaining the need for this dosage increase or describing any behavioral interventions considered prior to the change. Review of the medication administration records confirmed that the resident received the increased dosage as ordered. The Director of Nursing (DON) was unable to provide documentation of an IDT meeting or clinical justification for the medication change. The facility's policy requires that psychotropic drug use be based on comprehensive assessment and that gradual dose reductions and behavioral interventions be implemented unless contraindicated, with dosage reductions attempted per CMS guidelines unless clinically contraindicated. These requirements were not met in this instance.