Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints and unnecessary psychotropic medication use. The resident, admitted with diagnoses including anxiety, hallucinations, and disorientation, was prescribed haloperidol as needed for hallucinations or aggression. However, medication administration records, behavior monitoring, and progress notes showed that haloperidol was given on multiple occasions without documented indications for use. Nursing staff administered the medication for reasons such as difficulty sleeping, agitation, or being difficult to control, but did not consistently document the specific behaviors or symptoms that warranted its use. Interviews with several LPNs revealed uncertainty about the reasons for administering haloperidol and a lack of documentation regarding the resident's behaviors or the effectiveness of the medication. The Director of Nursing Services confirmed that haloperidol should only have been given for aggression or hallucinations and that staff were expected to document the specific behaviors, non-pharmacological interventions attempted, and the outcome of the medication administration. The absence of this documentation and the administration of haloperidol without clear indications constituted a failure to prevent the use of unnecessary psychotropic medications and chemical restraints.