Failure to Ensure Drug Regimen Free from Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of risperidone (Risperdal), an antipsychotic medication. The resident in question was an elderly female with diagnoses including paraplegia, mood disorder, and schizoaffective disorder. Her medical records, including the face sheet and MDS assessment, reflected severe cognitive impairment and the use of antipsychotic and antidepressant medications. The care plan documented the use of Risperdal for symptoms related to schizophrenia, such as mood changes and yelling, and included monitoring for adverse reactions and pharmacy review per facility policy. Upon review, it was found that the medical diagnosis supporting the use of Risperdal was inconsistently documented. While the care plan and some physician notes referenced schizophrenia or schizoaffective disorder, the official medical diagnosis in the resident’s records did not consistently reflect this until the day of the survey. The nurse practitioner and DON confirmed that the diagnosis of schizophrenia was only present in certain notes and the order entered into the electronic charting system, but not in other official paperwork. The diagnosis was added to the medical record on the day of the survey, and the nurse practitioner clarified that the correct diagnosis should be schizoaffective disorder, as originally given by the primary care provider. Interviews with facility staff, including the DON and LVN, revealed that medication orders are entered and double-checked by nursing staff, but if the wrong diagnosis is entered, it could result in an inappropriate medication regimen. The lack of a consistent and adequate indication for the use of Risperdal in the resident’s official medical record led to the finding that the facility failed to ensure the resident’s drug regimen was free from unnecessary drugs.