Psychotropic Medication Administered Without Indication
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication, specifically Cymbalta (an antidepressant), had an appropriate indication for administration as required. Review of the resident's electronic medical record showed an active order for Cymbalta without a documented reason for its use. The resident's diagnoses included hypertension, major depressive disorder, gallbladder calculus, and diabetes mellitus. Both annual and quarterly Minimum Data Set (MDS) assessments indicated the resident had intact cognition and was receiving multiple classes of medications, including psychotropics. The care plan documented staff education on proper medication administration, but did not address the lack of indication for the psychotropic medication order. Interviews with facility staff confirmed that every medication order should include an indication for use, and that orders lacking this information should be clarified. The facility's policy on chemical restraints and unnecessary psychotropic medications required that such medications only be used to treat specific medical symptoms and not for staff convenience or discipline. Despite these policies and staff expectations, the resident continued to receive Cymbalta without a documented indication, constituting a failure to comply with regulatory requirements for medication management.