Failure to Assess and Document Psychotropic Medication Use and Interventions
Penalty
Summary
The facility failed to periodically assess the use of psychotropic medications, identify and track resident-specific behaviors, attempt nonpharmacological interventions, and avoid duplicate therapy for three residents reviewed for unnecessary medications. For one resident, the Medication Administration Record (MAR) listed antipsychotic and antidepressant medications, but there was no documentation of nonpharmacological interventions or identification and tracking of specific behaviors. Another resident was prescribed both an antipsychotic and an antidepressant, yet there was no documented psychotropic medication assessment, no evidence of attempted nonpharmacological interventions, and no tracking of resident-specific behaviors. A third resident was found to be receiving two different antipsychotic medications concurrently, along with a sleep aid, without documented justification for the duplicate antipsychotic therapy. There was also no psychotropic medication assessment, no documentation of nonpharmacological interventions, and no identification or tracking of resident-specific behaviors for this resident. The Director of Nursing and Corporate Nurse Consultant confirmed that these assessments and interventions should have been documented for all three residents.