Failure to Prevent Unnecessary Psychotropic Medication Use and Ensure Least Restrictive Interventions
Penalty
Summary
The facility failed to ensure that five out of nine sampled residents were free from unnecessary psychotropic medications and chemical restraints, and did not consistently use the least restrictive approaches for their needs. Specifically, there was a lack of documentation for prescribed PRN antipsychotic medications, missing records of identified behaviors, and insufficient evidence of non-pharmacological interventions prior to medication administration. For several residents, care plans did not include medication-specific target behaviors or person-centered interventions, and behavior monitoring was either absent or not updated to reflect individualized approaches. For one resident with severe cognitive impairment and multiple psychiatric diagnoses, antipsychotic medications were administered without corresponding documentation of behaviors or non-pharmacological interventions. The medical record did not reflect the behaviors that justified the use of these medications, and care plans failed to include triggers or person-centered interventions. In another case, a resident with dementia and depressive disorder was prescribed antipsychotic medication, but there was no documentation of behaviors or mood charting as ordered, and recommendations from psychological assessments were not incorporated into care plans or behavior monitoring. Other residents with intellectual disabilities, schizoaffective disorder, and depression were also affected by similar deficiencies. Their care plans lacked individualized interventions, and behavior monitoring did not consistently document specific behaviors or the use and effectiveness of non-pharmacological interventions. Staff interviews revealed a lack of awareness regarding resident-specific interventions and inconsistent documentation practices. Additionally, trauma-informed care was not integrated into care plans or behavior monitoring for residents with identified trauma responses.