Psychotropic Medication Administered Without Accurate Diagnosis
Penalty
Summary
A resident was administered the psychotropic medication quetiapine for four days without an accurate or appropriate diagnosis documented in their clinical record. The medication was ordered for bipolar disorder, but the resident did not have a diagnosis of bipolar disorder; their admission record only listed depression among their diagnoses. The Medication Administration Record showed that quetiapine was given from March 7 to March 10, despite the lack of a proper indication for its use as required by facility policy. During interviews, the DON confirmed that the physician's order for quetiapine did not have an accurate diagnosis, emphasizing the importance of matching medications to the resident's documented conditions. The resident's physician also stated that a review of the medications should have been completed and that the facility should have clarified the rationale for prescribing a psychotropic medication. The facility's policy requires that psychotropic medications be used only when necessary and that the clinical record reflect the diagnosis and specific condition being treated, which was not followed in this case.