Failure to Prevent Unnecessary Psychotropic Medication Use Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was free from unnecessary psychotropic medications, resulting in a significant adverse event. The resident, who had severe cognitive impairment, anxiety, and a history of dementia without behavioral disturbances, was admitted with a PRN order for Xanax. Over time, the administration of Xanax was increased from as-needed to scheduled dosing, and a one-time dose of Risperidone was also administered. The decision to increase and add these medications was made following an elopement incident, with the physician relying on staff suggestions and family input, despite the lack of documented behavioral tracking or clear psychiatric indications for the medications. The facility's own policy required thorough assessment and documentation of behavioral symptoms before initiating psychotropic medications, which was not followed in this case. The resident received multiple doses of Xanax and was given Risperidone after initial refusal, with the involvement of family and a police officer to convince her to take the medication. Staff observations and interviews indicated that after the administration of these medications, the resident became increasingly drowsy, confused, and unsteady, with staff noting that she was kept in a wheelchair for safety due to her unsteady gait. Despite these changes, documentation in the medical record inaccurately reflected that the resident's gait was at baseline, and there was no evidence of ongoing behavioral tracking or reassessment of the necessity and effects of the psychotropic medications. Ultimately, the resident attempted to ambulate independently, lost her balance, and sustained a fall resulting in a right hip fracture that required surgical intervention. Staff interviews revealed concerns about the appropriateness of the psychotropic medication regimen, particularly the use of benzodiazepines in an elderly, ambulatory resident, and the lack of communication and assessment regarding the resident's changing condition. The physician acknowledged that the medications likely contributed to the fall and that the prescribed dosages were higher than typically recommended for geriatric patients.