Failure to Document Appropriate Indication and Physician Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that two residents with dementia diagnoses received antipsychotic medications only with appropriate indications and documented physician rationale. For one resident with moderately impaired cognition and diagnoses including dementia and Alzheimer's disease, the medical record showed ongoing administration of olanzapine for psychosis without documentation of risk versus benefit or evidence of unsuccessful nonpharmacological interventions. The pharmacy consultant had identified and reported irregularities related to the non-approved indication for this antipsychotic use, but the facility was unable to provide the required physician documentation upon request. For another resident with severely impaired cognition and Alzheimer's disease, quetiapine was administered for severe dementia with agitation. The medical record lacked a physician-documented rationale for the continued use of this antipsychotic for dementia-related behaviors, and no documentation of risk versus benefit was available. The care plan referenced attempts at gradual dose reduction and nonpharmacological interventions, but there was no supporting physician documentation for the ongoing use of the medication. Interviews with nursing staff and administration revealed uncertainty regarding appropriate indications for antipsychotic medications and a lack of awareness about the need for physician documentation of risk versus benefit. The facility's policy required monitoring the need for psychotropic medications and evaluating their effectiveness, but these requirements were not met in the cases reviewed, resulting in the administration of unnecessary psychotropic medications without proper justification.