Deficiencies in Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure proper documentation and monitoring for three residents reviewed. For one resident with anxiety disorder and vascular dementia, the physician's orders and informed consents for antipsychotic medications did not include the required diagnoses or specific behavioral manifestations. Additionally, there was no psychoactive medication evaluation or care plan initiated for the use of these medications, and a PRN antianxiety medication order lacked a required stop date. The medical record also did not specify the type of hallucinations being monitored, and the DON confirmed these omissions during interviews. Another resident, with a history of fluctuating capacity for decision-making, had physician's orders for orthostatic blood pressure monitoring that were not accurately followed, as identical readings were recorded for different positions, which staff acknowledged was incorrect. Furthermore, the same resident's behavior monitoring and documentation of nonpharmacological interventions related to antipsychotic use were inconsistent and inaccurate. Staff documented interventions even when no behaviors were observed and failed to document interventions when behaviors were present, as confirmed by interviews with nursing staff and the DON. A third resident was prescribed two antidepressant medications for the same behavioral manifestation of sadness, with both orders indicating the same indication. Nursing staff acknowledged that this duplication made it difficult to assess the effectiveness of each medication and that the orders should have been clarified with the physician. The DON later clarified that one medication should have been indicated for poor oral intake, but this was not reflected in the original documentation.