Failure to Prevent Chemical Restraint and Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints and unnecessary psychotropic medication use. A resident with severe cognitive impairment, dementia, diabetes, sleep apnea, and anxiety was admitted and prescribed multiple psychotropic medications, including donepezil, escitalopram, quetiapine, hydroxyzine, and lorazepam. The resident's care plan did not include any specific interventions for behavior management, identified target behaviors, or individualized interventions. Additionally, there were no behavior monitoring records for the resident during the relevant period. On one occasion, the resident became agitated during the night and refused oral lorazepam. The nurse obtained a telephone order for injectable lorazepam and administered it without offering the resident the option to refuse. The resident's representative was not informed of the new injectable medication order prior to its administration and stated they would not have consented. The Director of Nursing confirmed that administering a psychotropic medication without consent constituted a chemical restraint and that licensed nurses were expected to recognize and question such orders.