Failure to Document Indications for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs, including chemical restraints, by administering psychotropic medications without adequate documentation of specific target behaviors or appropriate indications for use. One resident with bipolar disorder and anxiety was prescribed aripiprazole and olanzapine for bipolar disorder, but the orders lacked detailed descriptions of the behaviors these medications were intended to address. The facility's Medication Regimen Review (MRR) questioned the appropriateness of these medications, noting that antipsychotics are not typically used for depression, especially when the manifestation is manic phases. During interviews, facility leadership acknowledged that the orders needed to specify behaviors to allow for accurate monitoring. Another resident with dementia was prescribed Depakote for behaviors manifested by dementia, but the order did not specify the particular behaviors being treated. The MRR repeatedly indicated that the documentation was insufficient to justify the use of Depakote. Facility staff confirmed that the recommendation to update the order with specific target behaviors was missed, partly due to the resident's hospitalization and subsequent hold on orders. The facility's policy requires that symptoms warranting psychotropic medication use be clearly identified, evaluated, and documented, which was not done in these cases.