Failure to Justify and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications, including antipsychotics and antianxiety drugs, were only prescribed and administered when clinically justified and properly documented. Multiple residents were prescribed PRN (as needed) psychotropic medications without clear documentation of a diagnosed specific condition or indication for use, as required by facility policy. In several cases, there was no evidence in the medical records or progress notes that residents exhibited behaviors or symptoms warranting the use of these medications, and behavior monitoring was either not documented or not transcribed onto the appropriate records. For example, one resident with chronic kidney disease and bipolar disorder was prescribed PRN olanzapine and lorazepam for agitation and anxiety, but there was no documentation of any episodes of agitation, anxiety, or related behaviors prior to the prescription. Staff interviews confirmed that the resident had not displayed aggressive or anxious behaviors, and there was no place in the electronic medical record to document such behaviors if they occurred. Similarly, another resident with severe dementia and psychotic disturbance was continued on a high dose of olanzapine despite only one documented episode of verbal aggression and paranoid delusions over several months. The rationale for continuing the medication at a higher-than-recommended dose was based on a single poor interaction with family, without ongoing documentation of targeted behaviors. Additionally, two other residents were prescribed PRN antianxiety medications for extended periods beyond the 14-day limit without proper physician rationale or evidence of anxiety. In one case, the only rationale provided for extending a PRN diazepam order was the resident's hospice status, which was later discontinued without updating the medication order or rationale. In another case, a resident was prescribed PRN lorazepam for anxiety or shortness of breath, but neither the resident nor their family reported a history of anxiety, and there was no documentation of anxiety or use of the medication. The facility's failure to document clinical indications, monitor behaviors, and ensure appropriate prescribing practices led to the deficiency.