Failure to Ensure Proper Management and Documentation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate management and documentation of psychotropic medications for multiple residents. For one resident with diagnoses including vascular dementia, anxiety, bipolar disorder, and major depressive disorder, the physician’s order for PRN Ativan lacked a required stop date, and the medication was administered without issue. The facility did not provide a policy for psychotropic medication use when requested, and the administrative nurse confirmed that the Ativan order should have included a stop date and reassessment by the physician. Another resident with Alzheimer’s disease, anxiety, and depression was prescribed Seroquel for anxiety and agitation, with the dose later increased. The care plan directed staff to consider dosage reduction quarterly, but the physician’s order did not include an appropriate indication or documentation of risk versus benefit for the antipsychotic use. The administrative nurse acknowledged that agitation was not an appropriate diagnosis for Seroquel and that the physician needed to provide ongoing justification for its use. The facility was unable to provide a policy for antipsychotic medication use upon request. A third resident with diabetes and major depressive disorder was prescribed sertraline, with the consultant pharmacist recommending a gradual dose reduction or rationale for continued use. There was no documented physician response to these recommendations, and the administrative nurse confirmed that the physician had not received or responded to the pharmacist’s recommendations. The facility’s pharmacy services policy required monthly medication regimen reviews and communication of recommendations, but the facility did not provide a specific policy for psychotropic drugs.