Failure to Prevent Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications for three out of five reviewed residents. For each of these residents, physician orders for Ativan, a psychotropic medication used to treat anxiety, did not include a required 14-day stop date, nor was there documented physician rationale for extending the medication beyond 14 days. The Medication Administration Records showed that these residents received Ativan multiple times over several months. Additionally, the facility's own policy required that non-pharmacological interventions be attempted and documented prior to administering psychotropic medications, but there was no evidence in the progress notes that such interventions were used or assessed for effectiveness before giving Ativan. The affected residents had various diagnoses, including anemia, hypertension, anxiety, dementia, and a cervical fracture. Despite these conditions, the clinical records and progress notes lacked documentation of non-pharmacological approaches prior to medication administration, as required by facility policy. The Director of Nursing confirmed that the facility did not ensure the medication regimens were free from unnecessary psychotropic medications for these residents.