Unnecessary Psychotropic Drug Increase Without Proper Orders or Consent
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and severe cognitive impairment had their Seroquel (Quetiapine) dosage increased from 25 mg twice daily to 50 mg twice daily without a documented physician order, clinical indication, or timely informed consent. The resident's records showed no increase in hallucination episodes to justify the dosage change, and the new order for Seroquel did not match the previously documented indication or monitoring for schizoaffective disorder. The Assistant Director of Nursing (ADON) stated she entered the new order based on a verbal instruction during an interdisciplinary team meeting, but could not find documentation of a physician's order or indication for the increase in the resident's electronic health record. Additionally, the required written informed consent for the psychotropic medication increase was not obtained from the resident's responsible party (RP) until over two months after the medication change was implemented. The consent form remained unsigned by both the RP and the physician during this period, and facility records indicated the RP was available for part of the time when the consent could have been obtained. Facility policy requires that psychotropic medications be clinically indicated, necessary, and supported by documented evaluation and consent, which was not followed in this case.