Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications for multiple residents. One resident with Alzheimer's disease and dementia was administered a high dose of quetiapine (Seroquel) for reported auditory hallucinations, but there was no documentation in the clinical record specifying the nature of these hallucinations or evidence that they caused harm or significant distress. Observations and interviews with staff and the resident's family indicated that while the family reported past behavioral symptoms, there was no current documentation or monitoring of such symptoms in the facility records to justify the ongoing use of the medication. Another resident with bipolar disorder and depression was prescribed both Seroquel and fluoxetine, but the clinical record lacked evidence that non-drug interventions were attempted prior to administering these psychotropic medications. The Director of Nursing confirmed that nursing staff did not document any non-pharmacological approaches before medication administration, as required by facility policy. A third resident with depression received PRN lorazepam without a stop date, and the clinical record did not show that a physician had reassessed the need for continued use of the medication after 14 days, as required. The DON acknowledged the absence of physician re-evaluation and documentation for the ongoing PRN order. Facility policies require non-pharmacological interventions to be attempted and PRN psychotropic orders to be time-limited unless properly justified, but these procedures were not followed for the residents involved.