Inadequate Diagnosis and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident had an appropriate diagnosis for the use of psychotropic medications and did not adequately monitor the resident's behaviors. The resident, who had diagnoses including dementia with psychotic disturbance, anxiety disorder, and major depressive disorder, was prescribed an antipsychotic (Quetiapine) for crying and restlessness related to dementia. However, documentation showed minimal recorded behaviors, with only two instances of restlessness noted by nursing staff and no behaviors documented by nurse aides over a one-month period. Progress notes were repetitive and lacked specific details about the resident's behaviors, such as wandering or taking items, despite these being described as regular occurrences. Observations confirmed that the resident was frequently wandering the unit, but this behavior was not consistently documented in the medical record. Interviews with facility staff verified that the antipsychotic was prescribed for dementia, which was not considered an appropriate diagnosis for such medication, and that behavior monitoring was insufficient. The lack of accurate and thorough documentation, as well as the use of psychotropic medication without a proper diagnosis, contributed to the deficiency identified during the survey.