Failure to Reduce Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to prevent the use of chemical restraints for one resident with vascular dementia and depression, who was prescribed Seroquel, Depakote, and Mirtazapine. Despite documentation that Seroquel was mostly ineffective and provider notes indicating a goal to discontinue it due to medication class risk, no dose reduction was attempted after Depakote was initiated. Observations over several days showed the resident was often sleepy or had eyes closed, and staff interviews confirmed the resident had not exhibited behaviors for about a month and was redirectable when behaviors had occurred. Staff also reported the resident was frequently sleepy during activities and sometimes did not attend due to this sleepiness. Review of records showed that although monthly psychoactive monitoring summaries documented Seroquel as mostly ineffective, the rationale for not reducing the dose was to continue the current plan of care. Interviews with nursing and social services staff confirmed that no dose reduction was attempted after starting Depakote, and the psychiatric nurse practitioner stated it was clinically contraindicated due to ongoing behaviors, despite staff observations to the contrary. The lack of timely dose reduction and continued use of Seroquel without clear evidence of ongoing behaviors led to the use of unnecessary psychotropic medication and potential chemical restraint.