Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications and that appropriate monitoring and documentation were in place for those receiving such medications. For one resident with dementia, Seroquel and Ativan were administered without a documented diagnosis of bipolar disorder or psychosis, and informed consent was not obtained prior to starting Seroquel. Additionally, there was no evidence that least restrictive measures or non-pharmacological interventions were attempted before initiating these medications, and side effect and behavioral monitoring were not implemented until several days after the medications were started. Another resident was prescribed divalproex sodium and Prozac, but the facility did not complete monthly behavior summaries for the targeted behaviors associated with these medications. Furthermore, after the resident was readmitted, the facility failed to obtain an order for orthostatic hypotension monitoring related to the resident's ongoing use of Zyprexa, an antipsychotic medication known to carry this risk. The absence of required monitoring and documentation was confirmed by facility leadership during interviews and record reviews. A third resident was prescribed Zyprexa for schizophrenia, with the targeted behavior for monitoring changed in the medical record. However, the facility did not complete monthly behavior summaries for the new targeted behavior after the change was made. Staff interviews confirmed that the required documentation was not completed, and facility policy requires such summaries to be updated whenever there are changes in medication orders, diagnoses, or manifestations.