Failure to Document Non-Pharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to properly identify and document non-pharmacological interventions and targeted behaviors in the care plans for two residents who were prescribed high-risk medications. For one resident with a history of stroke, aphasia, and anxiety, the care plan did not specify targeted behaviors to monitor in relation to prescribed antipsychotic and psychotropic medications, nor did it include non-pharmacological interventions to be attempted prior to administering opioid medication for chronic pain. The Director of Nursing confirmed that these elements should have been included in the care plan. For another resident with severe cognitive impairment and a diagnosis of senile degeneration of the brain, the care plan noted the use of an antidepressant for insomnia but only included interventions to administer the medication and monitor for side effects and effectiveness. The clinical record did not contain documentation of a Gradual Dose Reduction (GDR) for the antidepressant, despite the pharmacy consultant having requested it multiple times. The facility's policy on psychotropic medications did not specifically address GDRs, and no evidence of a completed GDR was found in the resident's records.