Failure to Individualize Psychotropic Medication Use and Behavior Monitoring
Penalty
Summary
The facility failed to ensure that two residents were free from chemical restraints and that psychotropic medications were used only with appropriate, individualized, and least restrictive approaches. For both residents, the care plans and documentation did not include resident-specific behaviors, triggers, or person-centered interventions related to the use of psychotropic medications. Instead, the facility relied on generic templates for behavior monitoring and non-pharmacological interventions, which were not tailored to the individual needs or documented behaviors of the residents. For one resident with severe cognitive impairment, anxiety, and depression, the care plan interventions and medication orders referenced monitoring for generic symptoms such as tearfulness and nervousness, but there was no documentation in the medical record, medication administration records, or progress notes to indicate that the resident exhibited any behaviors justifying the continued use of psychotropic medications. The resident expressed feelings of loneliness and anxiety related to her husband’s absence, and staff reported that reassurance and facilitating communication with her husband were effective interventions. However, these specific expressions and interventions were not reflected in the care plan or behavior monitoring documentation. For another resident with moderate cognitive impairment and major depressive disorder, the care plan and physician orders also used generic behavior monitoring and interventions, failing to address resident-specific behaviors such as isolation, obsessions, need for routine, and hoarding tendencies identified in the PASRR evaluation. The documentation did not indicate any behaviors that would justify the use of psychotropic medications, nor did it reflect the resident’s preference for solitude or the triggers identified by family and staff. Staff interviews confirmed that behavior monitoring and interventions were not individualized, and that staff primarily used generic templates rather than customizing care to the residents’ needs.