Failure to Ensure Appropriate Use and Documentation for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that several residents were free from unnecessary antipsychotic medication use without appropriate clinical indications or documented gradual dose reductions (GDRs). Specifically, four residents were administered antipsychotic medications for diagnoses such as dementia and psychosis, but the medical records lacked evidence of appropriate indications for use, physician-documented risk versus benefit statements, or recent attempts at GDRs. In several cases, the care plans directed staff to consult with pharmacy and physicians regarding dose reductions and to educate residents and families about the risks and benefits of these medications, but there was no documentation that these steps were consistently followed. For one resident with diagnoses including psychosis, Alzheimer's disease, and dementia with agitation, the electronic medical record showed ongoing antipsychotic medication orders with no recent GDR attempts or consultant pharmacist recommendations for continued use. Another resident with severe cognitive impairment and multiple behavioral symptoms was receiving two antipsychotic medications, but the consultant pharmacist's review did not include recommendations for appropriate indications. A third resident, newly admitted with dementia and other comorbidities, was prescribed an antipsychotic for dementia without an approved indication, and the consultant pharmacist had not yet reviewed the case. A fourth resident with multiple diagnoses, including dementia and psychosis, was on a high dose of antipsychotic medication, but the record lacked a physician-documented rationale for the risks versus benefits of continued use. Interviews with nursing staff and administration revealed uncertainty about appropriate indications for antipsychotic use, with staff acknowledging that dementia alone should not be used as a justification. The facility's own policy required that only necessary medications be used, with documentation of adequate indicators for use and regular evaluation of ongoing need, but these requirements were not met in the reviewed cases. Observations of the residents confirmed their ongoing use of antipsychotic medications without the necessary supporting documentation or clinical justification.