Failure to Individualize Psychotropic Medication Use and Documentation
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraint and that the use of psychotropic medications was properly justified and documented. For each of these residents, the facility did not document resident-specific care approaches, including medication-specific target behaviors and person-centered interventions. The care plans and physician's orders relied on generic, non-personalized interventions for behavior monitoring, and did not incorporate individualized strategies or interests identified in assessments such as the Level II PASRR. Additionally, there was a lack of documentation regarding the effectiveness of interventions used, and in some cases, no interventions were documented at all when behaviors occurred. For one resident with a diagnosis of disorganized schizophrenia, the care plan and behavior monitoring orders listed the same non-person-centered interventions for all behaviors, regardless of the specific issue. The resident's history of psychiatric symptoms, self-harm, and interests were not reflected in the care plan or orders. Documentation in the medication administration and treatment records showed minimal or no behaviors, and when behaviors were noted, the effectiveness of interventions was not recorded. There was also no documentation of a physician's rationale for the continued use of antipsychotic medications, despite quarterly reviews indicating no recent behaviors. Another resident with diagnoses including Parkinson's disease, anxiety, OCD, and depression had behavior monitoring orders that did not specify non-pharmacological interventions. The care plan did not reflect the resident's specific behaviors or interests as identified in the PASRR evaluation. Documentation showed minimal behavioral incidents, with no evidence of non-pharmacological interventions being attempted. Similarly, a third resident with depression, intellectual disability, and TBI had no non-pharmacological interventions indicated in the orders, and the care plan did not address specific behaviors or interests. Despite concerns documented by the psychiatrist regarding the rationale for increased medication dosage, the medication was not adjusted, and there was no documentation justifying its continued use. Staff interviews confirmed a lack of awareness of individualized interventions and reliance on generic documentation.