Failure to Prevent Unnecessary Use of Psychotropic Medications and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraints and that the least restrictive approaches were used to address their needs. Specifically, the facility did not include resident-specific non-pharmacological interventions in the behavior care plans for two residents, nor did it document consistent behaviors to justify the continued use of psychotropic medications. Additionally, the care plans lacked documentation of medication-specific target behaviors and person-centered interventions for the psychotropic medications administered to these residents. For another resident, the facility did not ensure that gradual dose reductions (GDR) were attempted for psychotropic medications as required. For one resident with severe cognitive impairment and diagnoses including Alzheimer’s disease, anxiety, and depression, the care plans addressed potential for physical aggression and wandering but did not specify person-centered non-pharmacological interventions. Physician orders included multiple psychotropic medications, but behavior monitoring orders failed to address all identified behaviors, such as physical aggression and wandering. Documentation in the medical record and medication administration records was inconsistent or absent regarding observed behaviors, interventions attempted, and their effectiveness. Staff interviews revealed a lack of knowledge about non-pharmacological interventions and inconsistent documentation practices. Another resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and insomnia, was prescribed antipsychotic and antidepressant medications. The care plans did not include person-centered non-pharmacological interventions, and there was no physician order to monitor behaviors related to antipsychotic use. Documentation of behaviors and interventions was lacking in the medical record, and staff were unable to consistently describe or document effective interventions. For a third resident with multiple psychiatric diagnoses, the facility did not consistently attempt or document GDRs for psychotropic medications, and when GDRs were contraindicated, the physician did not always provide a rationale. The resident expressed concerns about being on too many medications, and documentation of behaviors and medication reviews was incomplete.