Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the care of three residents. One resident with multiple neurocognitive and psychiatric diagnoses was prescribed as needed Haloperidol for agitation and restlessness, but there was no documentation that the prescribing practitioner directly examined the resident every 14 days to assess the continued need for the medication, as required. The resident received the medication on multiple occasions, and the as needed order remained active for an extended period without the necessary evaluations or new orders. Another resident with severe cognitive impairment and psychiatric diagnoses received frequent doses of as needed Lorazepam for anxiousness, but the facility lacked documentation from the prescribing practitioner justifying the extended use or specifying the duration for the medication. Additionally, a third resident with dementia and psychiatric conditions was maintained on a daily antipsychotic medication despite a consultant pharmacist's recommendation for gradual dose reduction due to the absence of documented behaviors. The recommendation was not communicated to the prescriber, and the resident continued to receive the medication without documented indication for its ongoing use.