Failure to Justify and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were as free from unnecessary psychotropic medications as possible, as evidenced by the lack of appropriate clinical justification, monitoring, and documentation for the use of such medications in three out of five residents reviewed. For one resident, there was no documented physician rationale for the concurrent use of three antidepressant medications, despite the resident experiencing significant drowsiness and sleeping up to sixteen hours per day. The physician could not recall if a rationale for the use of multiple antidepressants was documented, and the medical record did not provide justification for the continued use of trazodone in the context of excessive sleep. Two other residents were found to be receiving psychotropic medications, including antidepressants and antipsychotics, without proper mood and behavior monitoring or documentation of target behaviors to justify the use of these medications. Their care plans did not specify which behaviors or symptoms were being targeted by the medications, and there was no mood or behavior tracking documented in their treatment administration records. Additionally, one resident was prescribed an antipsychotic without a documented diagnosis or adequate indication for its use in the medical record. Staff interviews confirmed that the facility did not have a system in place for mood or behavior tracking related to psychotropic medication diagnoses, and only tracked medication side effects. The social services assistant, pharmacy consultant, and DON all acknowledged the absence of specific mood and behavior care plans and tracking, which are necessary to evaluate the effectiveness and ongoing need for psychotropic medications. The facility's own policy required documentation of adequate indications for medication use and proper monitoring, which was not followed in these cases.