Hypnotic Medication Administered Without Proper Indication or Monitoring
Penalty
Summary
A deficiency was identified when a resident was prescribed Ambien, a hypnotic medication, for sleep assistance without an appropriate diagnosis or medical indication documented in the medical record. The resident, who had diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction, did not have a documented sleep disorder or related diagnosis to justify the use of Ambien. The physician's order for Ambien was present, but the necessary clinical justification was absent. Further review revealed that the resident's care plan did not address the use of Ambien, nor did it outline any monitoring for the effects or adverse consequences of the hypnotic medication. Interviews with the DON confirmed both the lack of an appropriate diagnosis for hypnotic use and the absence of a care plan for monitoring. The facility's policy required that psychotropic medications be clinically indicated and that residents be monitored for adverse effects, but these requirements were not met in this case.