Deficient Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medication use and chemical restraints, as evidenced by multiple deficiencies in the management of psychotropic medications for two residents. For one resident with a history of traumatic brain injury, depression, and anxiety disorder, the facility did not provide ongoing re-evaluation of the need for PRN lorazepam, as the medication was ordered without an end date and continued indefinitely. The orders for lorazepam also lacked specific, measurable behavioral manifestations to guide administration, and there was no consistent monitoring for adverse effects following administration. Additionally, there was no documented evidence of informed consent being obtained prior to the administration of the psychotropic medication, as required by facility policy. Interviews with facility staff, including the MDS nurse, RN, and ADON, confirmed that the facility's process for psychotropic medication management was not followed. Staff acknowledged that PRN psychotropic medications should be ordered with a stop date, monitored for specific behaviors, and that informed consent must be obtained and documented. Review of the medication administration record revealed multiple instances where lorazepam was administered without documentation of side effect monitoring, and the informed consent form did not indicate who provided consent or when it was obtained. For another resident with dementia and a history of alcohol abuse, the facility failed to ensure that the antipsychotic medication risperidone was used only with a clear, documented indication. The resident's clinical record did not contain a confirmed diagnosis of schizophrenia, which was listed as the reason for the risperidone prescription. The diagnosis was questioned in psychiatric notes, and neither the care plan nor the MDS included schizophrenia as an active diagnosis. The resident and her representative were not aware of a schizophrenia diagnosis, and the DON confirmed that the use of risperidone without a clear, confirmed diagnosis was not appropriate. Facility policies required a comprehensive assessment and documentation of a specific condition for psychotropic medication use, which was not met in this case.