Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper documentation and monitoring for the use of psychotropic medications for three out of five residents reviewed. For one resident with dementia and depression, Risperidone was prescribed without a documented allowable diagnosis to support its use, and the diagnosis of 'depression with psychotic features' was not consistently reflected in the medical record or on the active diagnoses list. The resident's care plan and behavioral documentation were incomplete, and not all possible side effects listed in the informed consent were included on the treatment administration record for staff monitoring. Additionally, a pharmacy recommendation for a gradual dose reduction (GDR) of Risperidone was not acknowledged or acted upon by the physician, and there was a lack of clear process ownership for monitoring psychotropic medications among staff. Another resident received multiple PRN (as needed) orders for Ativan, an antianxiety medication, with durations exceeding the regulatory 14-day limit for PRN antianxiety medications. These orders were not appropriately limited or reviewed within the required timeframe, indicating a failure to comply with federal regulations regarding the use of PRN psychotropic medications. A third resident was prescribed both an antipsychotic (Olanzapine) and an antidepressant (Trazodone) without corresponding physician orders for monitoring side effects. The Director of Nursing confirmed that monitoring for side effects should have been ordered and documented, but could not provide evidence that this was done. The facility's policy required monitoring for efficacy, side effects, and adverse consequences of psychoactive medications, but this was not followed for the resident in question.