Unnecessary Antidepressant Prescribed Despite Resident's Stated Weight Loss Goal
Penalty
Summary
A resident with type 2 diabetes mellitus and severe cognitive impairment was admitted to the facility and expressed a desire to lose weight, setting a goal of 145 lbs. The resident's care plan and weekly weight notes consistently documented this weight loss goal and the resident's motivation to lose weight for personal reasons. Despite this, an order was placed for an antidepressant to be administered daily, with the stated reason being abnormal weight loss. The resident's weight records showed a decrease from 155 lbs to 148 lbs, aligning with their stated goal, and later an increase to 153 lbs. The resident was not informed that the antidepressant was prescribed to address weight loss and continued to express a desire to lose more weight. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's weight loss intentions. The DON confirmed the resident's goal and acknowledged that the antidepressant was started after weight loss was observed, but could not confirm if it was recommended by the dietician or the MD. The MD stated the antidepressant was for depression but could not recall if the resident had a depression diagnosis or if a gradual dose reduction had been considered. The administrator was unaware of the resident's weight loss goal. Facility policy required medication use to be consistent with the individual's condition, prognosis, values, wishes, and responses to treatment, but this was not followed in this case.