Failure to Ensure Clinical Indication and Coordination for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were clinically indicated and necessary for four residents, resulting in the administration of unnecessary medications. Clinical record reviews and interviews revealed that residents were prescribed multiple psychotropic drugs, including antipsychotics and antidepressants, without adequate documentation of the specific conditions these medications were intended to treat. In several cases, the medications prescribed, such as Seroquel and Haloperidol, were not indicated for the residents' documented diagnoses or symptoms, and there was a lack of evidence supporting their use for conditions like anxiety, agitation, or insomnia. For example, one resident received Seroquel and Haloperidol for anxiety and agitation, despite these medications being FDA-approved for schizophrenia and bipolar disorder, not for anxiety or restlessness as documented in the resident's records. The facility also failed to coordinate care between psychiatric providers and primary care providers. There was no documentation that staff communicated with the psychiatric nurse practitioner regarding the administration of certain psychotropic medications, such as Haloperidol, or about changes in the residents' symptoms. Nursing staff reported administering these medications based on primary care physician orders without consulting the psychiatric provider, and the psychiatric nurse practitioner confirmed she was not informed about the use of these medications or the residents' increased anxiety. The Director of Nursing was unaware of the administration of some psychotropic medications and acknowledged the lack of communication and documentation regarding these interventions. Additionally, care plans and progress notes lacked required documentation, such as ongoing review of the need for psychotropic medications, monitoring and recording of target behaviors, and evaluation of non-pharmacological interventions. In some cases, residents were prescribed psychotropic medications without a corresponding mental health diagnosis, and there was no evidence that alternative therapies or behavioral interventions were attempted or documented. Interviews with staff and responsible parties further highlighted concerns about the appropriateness and effectiveness of the medications being administered.