Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as evidenced by the care of five residents reviewed for unnecessary medications or pain. For these residents, psychotropic medications were administered without adequate indications for use, and resident-specific target behaviors (TBs) were not properly identified or monitored. In several cases, gradual dose reductions (GDRs) were not performed, and non-drug interventions were not attempted or documented prior to the administration of as-needed (PRN) psychotropic medications. Additionally, PRN psychotropic medication orders exceeded 14 days without documented clinical rationale or provider reassessment. One resident with diagnoses of depression, anxiety, and bipolar disorder was prescribed buspirone and duloxetine, but the TBs listed in the care plan were simply restatements of diagnoses rather than specific behaviors, making it impossible to assess medication effectiveness. Another resident with severe cognitive impairment and a history of delirium and depression was prescribed two antipsychotics and an antidepressant, but the care plan failed to identify goals or TBs for these medications. The antipsychotics were continued after the resolution of delirium, with no clear indication for ongoing use, and no documentation of GDRs or rationale for continuation. Other residents were prescribed PRN lorazepam for anxiety or agitation, but orders were written for extended periods (up to six months) without provider reassessment every 14 days or documentation of clinical rationale for ongoing use. Non-pharmacological interventions were not individualized or documented prior to medication administration, and staff were unable to specify or monitor TBs linked to each medication. In some cases, medication orders lacked end dates, and staff interviews confirmed that documentation and monitoring practices did not meet expectations, with missing or inadequate records of behaviors and interventions.