Failure to Identify and Document Targeted Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that targeted behaviors were identified and documented for the use of antipsychotic medication in a resident with severely impaired cognition. The resident, who had a diagnosis of dementia with and without psychotic disturbance, was routinely administered risperidone, an antipsychotic medication. Clinical assessments, including the Minimum Data Set (MDS) and Preadmission Screening, indicated that the resident did not exhibit hallucinations, delusions, or behavioral disturbances, and had not shown behaviors while hospitalized prior to admission. Despite this, the care plan and physician orders referenced the use of antipsychotic medication for symptoms such as mild depression and psychotic features, but did not specify or describe the targeted behaviors that warranted the medication's use. Review of the resident's care plan and interventions revealed a lack of documentation regarding the specific behaviors or symptoms that justified the ongoing use of risperidone. The care plan noted a gradual dose reduction was declined due to continued symptoms, but did not detail what those symptoms were or how the resident's psychotic features manifested. Behavior monitoring records over the past 30 days showed only minimal episodes, such as two instances of anxious/restless behavior and one episode of elopement/exit seeking, with no consistent or significant behavioral issues documented. Interviews with nursing staff and CNAs further confirmed that the resident generally did not display problematic behaviors, with only occasional confusion, minor irritability, or missed toileting events reported. The facility's policy required that psychotropic medications be used only when appropriate to treat a specific, diagnosed, and documented condition, with ongoing monitoring and documentation of the resident's response. However, the documentation for this resident did not meet these requirements, as there was no clear identification or monitoring of targeted behaviors associated with the antipsychotic use. The deficiency was identified through observation, interview, and clinical record review, highlighting a failure to comply with facility policy and regulatory expectations regarding the use of psychotropic medications.