Failure to Prevent Unnecessary Use of Psychotropic Medications and Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from chemical restraints and unnecessary psychotropic medications. A resident with diagnoses including dementia with agitation, anxiety, depression, and unsteadiness was administered Zoloft and Ativan for depression and anxiety/behaviors. Despite the use of these medications, staff documented that Ativan was often ineffective in controlling the resident's restlessness and anxiety, yet additional doses were administered. The resident was observed repeatedly sitting in a Broda chair, appearing confused, fidgeting, and at times drowsy or sedated. Review of the clinical record revealed that the resident received frequent PRN doses of Ativan, with multiple instances documented as ineffective. There was a lack of consistent assessment for the effectiveness of both Ativan and Zoloft, and behavior monitoring was not routinely completed as required. The care plan for anxiety did not include resident-specific non-pharmacological interventions to address anxiety, restlessness, or behaviors prior to administering medication. Additionally, there was no documentation of a thorough assessment by a mental health professional, despite ongoing behavioral concerns and medication adjustments. Progress notes and therapy documentation indicated that the resident experienced increased confusion, functional decline, and drowsiness, which were associated with the increased administration of Ativan. Staff interviews confirmed that psychological consultations were not requested or documented, and that behavior and side effect monitoring were inconsistent. The facility's own policy required non-pharmacological interventions and behavioral programming to be attempted before psychotropic medications were used, but these steps were not documented or implemented for this resident.