Unnecessary Antipsychotic Use Without Supporting Documentation
Penalty
Summary
A resident was admitted with multiple diagnoses, including hypertension, type 2 diabetes, unspecified dementia without behavioral disturbance, and anxiety. Initial and quarterly assessments indicated no evidence of psychosis, behavioral symptoms, or a diagnosis of schizophrenia. Behavioral notes documented no psychiatric history and no further need for psychological intervention. Despite this, the resident was prescribed Risperdal, an antipsychotic medication, for 'psychosis with paranoia/auditory hallucinations' after being observed scratching himself. The care plan focused on administering psychotropic medication and documenting behaviors but did not include resident-centered interventions specific to the scratching behavior or address the circumstances surrounding it. Behavior monitoring records showed no observed behaviors during the relevant period. A nurse reported the resident was generally happy, with only a brief mention of expressed worries at night. Following a visit from a Mental Health Nurse Practitioner, the Risperdal dose was increased and a new diagnosis of schizophrenia was added, despite documentation indicating no psychotic symptoms. The facility was unable to provide documentation supporting the new diagnosis or the medication increase, and the behavioral services group emphasized the need for extensive documentation and clear symptoms before such changes. No further explanation or documentation was provided by facility leadership.