Failure to Monitor and Document Psychotropic Medication Use and Required Interventions
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications and that required monitoring and nonpharmacological interventions were implemented and documented as ordered. For one resident with moderately impaired cognition and diagnoses including schizoaffective disorder, depression, and anxiety, physician orders and care plans required regular monitoring of orthostatic blood pressure (BP) in multiple positions and the use of non-drug interventions prior to administering psychotropic medications such as quetiapine, aripiprazole, duloxetine, and lorazepam. However, medical record reviews revealed that orthostatic BP was not accurately or fully documented, with missing readings for required positions. Additionally, when behavioral episodes such as inconsolable screaming, anxiety, and disorganized speech were observed, the nonpharmacological interventions were either not attempted, not documented, or marked as 'not applicable' or '0', even when the behaviors were present and medications were administered. Further review of medication administration records showed that the resident received PRN lorazepam on multiple occasions without documentation of attempted or effective nonpharmacological interventions, and sometimes even when no behavioral episode was documented. Interviews with nursing staff and the ADON confirmed that the required interventions and documentation were not consistently completed, and that PRN medications were sometimes given despite documentation that nonpharmacological interventions were effective or not attempted at all. The ADON also verified that orthostatic BP monitoring was incomplete and not properly recorded in the resident's records. For a second resident, also with moderately impaired cognition and prescribed quetiapine for psychosis, physician orders and care plans required weekly orthostatic BP monitoring in different positions to detect potential orthostatic hypotension. However, medication administration records showed that BP readings were either identical across different positions or missing for some positions, indicating that the monitoring was not performed as ordered. The ADON confirmed that BP readings should differ between positions and acknowledged the incomplete documentation. Facility leadership was informed of these findings and acknowledged the deficiencies.