Failure to Prevent Unnecessary Psychotropic Medication Use and Ensure Proper Documentation
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, resulting in two deficiencies involving two residents. In the first case, a resident with diagnoses including Parkinson's disease, dementia, anxiety, depression, and psychotic disorder was administered an antipsychotic medication (Haldol) via injection after the physician's order for the medication had already been discontinued earlier that day. Documentation in the clinical record confirmed the administration of the medication without a current physician's order, and the Medication Administration Record did not reflect that the medication was given on that date. Interviews with staff revealed a lack of recall regarding the incident and a delay in follow-up after the medication was administered. In the second case, another resident with anxiety, osteoporosis, depression, and early-onset cerebellar ataxia was receiving both an antipsychotic and an antianxiety medication. The clinical record showed ongoing administration of these medications, with care plans indicating the need to consult with the healthcare provider for possible dosage reduction. However, there was no documentation of a contraindication for a gradual dose reduction (GDR) or a rationale from the prescribing practitioner to continue the medications at the current dose. The facility's policy required attempts at GDR unless clinically contraindicated and documented by the physician, but such documentation was not present in the resident's record. Facility policies reviewed included requirements to verify physician orders before administering intramuscular injections and to attempt GDRs for psychotropic medications unless contraindicated and documented. Staff interviews confirmed that orders should be obtained and documented for such medications, and that the required documentation for GDR contraindications was not available in the clinical record for the resident in question.