Failure to Document Indication and Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication, specifically an antipsychotic, had an appropriate clinical indication or a documented physician rationale for its continued use. The resident had diagnoses of depression and anxiety, with cognitive impairment documented over time. Despite the use of antipsychotic and antidepressant medications, there was no evidence in the medical record of behaviors that would warrant antipsychotic use, nor was there documentation of unsuccessful nonpharmacological interventions or a risk versus benefit analysis for the continued use of the antipsychotic. The resident's care plan included general instructions for monitoring and consulting with the pharmacy and physician, but lacked specific documentation of attempts at gradual dose reduction or alternative therapies. Review of the medication regimen and pharmacy consultant notes did not identify a clear diagnosis or justification for the antipsychotic medication, and staff interviews confirmed uncertainty regarding the appropriateness of the diagnosis for the medication. The facility was unable to provide a policy on psychotropic medication use. These actions and omissions resulted in the resident being at risk for adverse effects associated with unnecessary psychotropic medication use.