Failure to Prevent Unnecessary Psychotropic Medication and Chemical Restraint
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and chemical restraints for two residents. One resident with quadriplegia, severe cognitive impairment, and total dependence on staff was administered Seroquel, an antipsychotic, for depression, despite the absence of a psychiatric or mood disorder diagnosis and no CMS-approved indication for antipsychotic use in depression. The resident also received PRN Lorazepam for anxiety with an indefinite order lacking a required stop date. The consultant pharmacist identified these issues, noting the inappropriate use of Seroquel for depression and the need for a defined duration for Lorazepam, but the orders were not appropriately updated or discontinued as required. Another resident with paraplegia and intact cognition received antipsychotic medications, including Diazepam and Seroquel, for muscle spasms and insomnia, respectively. The Diazepam orders were PRN without a 14-day stop date or specific duration, and Seroquel was prescribed for insomnia, which is not an approved indication for antipsychotic use. The consultant pharmacist recommended clinical rationale and duration for Diazepam and questioned the indication for Seroquel, but the facility was unable to provide appropriate physician documentation for the use of antipsychotics with non-approved indications. Interviews with nursing staff and administrative nurses confirmed that antipsychotic medications should not be used for depression or insomnia and that PRN psychotropic medications require a 14-day stop date and physician evaluation for continued use. The facility's own policy also required these safeguards, but they were not followed. These actions and inactions resulted in the administration of unnecessary psychotropic medications and the risk of chemical restraint for the affected residents.