Deficient Psychotropic Medication Management and Oversight
Penalty
Summary
The facility failed to ensure proper management and oversight of psychotropic and related medications for several residents, as evidenced by multiple deficiencies in physician order clarification, gradual dose reduction (GDR) processes, PRN medication stop dates, and monitoring requirements. For one resident, the physician's order for an antidepressant was not clarified regarding its indication, despite the resident having multiple comorbidities including atrial fibrillation, COPD, and heart failure. Nursing staff and administration acknowledged that clarification should occur when an order is unclear or has an unusual indication, but this was not done in this case. Another resident receiving antipsychotic medication did not have documentation of a GDR attempt or a physician's statement that a GDR was contraindicated, as required by facility policy. Consulting pharmacist recommendations for GDR were not addressed by the physician, and monthly medication reviews were missing for several months. The director of nursing was expected to ensure these reviews were completed and retained, but this did not occur. Additionally, two residents had PRN orders for antianxiety medications (Lorazepam and Ativan) that lacked the required 14-day stop dates. Nursing staff were unaware of this requirement, and the director of nursing was responsible for entering orders and reviewing pharmacy recommendations. Another resident prescribed antidepressant medication did not have documented monitoring of behaviors for anxiety and depression, and staff were unaware that such monitoring was necessary. These failures were contrary to facility policies on order transcription, physician order clarification, and psychotropic drug management.