Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that three of five sampled residents were free from unnecessary psychotropic medications and that appropriate monitoring and documentation were in place. For one resident with a history of dementia and schizophrenia, the facility did not accurately monitor orthostatic blood pressure as ordered by the physician for the use of risperidone, an antipsychotic. The blood pressure readings recorded for lying, sitting, and standing positions were identical on multiple occasions, which was verified by the DON as not possible if the procedure was performed correctly. Additionally, there was no evidence that nonpharmacological interventions were attempted prior to the initiation of mirtazapine, an antidepressant, nor was there documentation of monitoring for side effects related to this medication. Another resident prescribed Seroquel for psychosis was also not properly monitored for orthostatic hypotension. The medical record showed that blood pressure readings for different positions were the same on several dates, which was confirmed by nursing staff and the DON as incorrect. The care plan for this resident included monitoring orthostatic blood pressure as an intervention, but the documentation did not reflect accurate or appropriate monitoring as required by the physician's orders. A third resident received multiple PRN orders for zolpidem tartrate, a sedative-hypnotic, with each order extending beyond the initial 14-day period. The facility's policy requires a documented clinical rationale from the prescribing physician for continued PRN use beyond 14 days, but the medical record did not contain such documentation for the extensions. The DON confirmed the absence of the required clinical rationale in the resident's record for the continued use of zolpidem tartrate.