Failure to Document Behaviors and Non-Pharmacological Interventions Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to properly track and document specific behaviors and non-pharmacological interventions prior to administering psychotropic medications for two residents. For one resident with a history of fetal alcohol syndrome, intellectual disabilities, and various behavioral issues, the care plan listed multiple behaviors, but the Medication Administration Record (MAR) only showed check marks or a code for behavior without corresponding progress notes detailing the specific behaviors or any non-pharmacological interventions attempted. The administrator confirmed that there was no documentation describing what behaviors occurred or what interventions were tried, and that the behaviors listed on the care plan did not match those recorded on the MAR. During the survey, this resident was observed to be pleasantly confused and interacted with staff and other residents without agitation or aggression. Another resident, admitted with severe unspecified dementia, agitation, anxiety disorder, and depression, was prescribed antipsychotic and antianxiety medications. The care plan indicated the use of these medications but did not specify the indications for use. The MARs for several months documented behavior monitoring but did not specify the behaviors or any non-pharmacological interventions. Progress notes for this resident recorded combative and resistive behaviors but did not document any attempted interventions during these behaviors or prior to administering psychotropic medications.