Failure to Ensure Timely Review and Limitation of Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that residents were free from chemical restraints and that psychotropic medications were not used for purposes of discipline or convenience, but only as required to treat medical symptoms. Specifically, two residents with intact cognitive function were prescribed Klonopin, a psychotropic medication, on an as-needed basis for periods exceeding 14 days. In both cases, the pharmacist requested that the prescribing physician provide a specific duration and stop date for the medication, but these requests were not addressed by the physician. For one resident with diagnoses including COPD, peripheral vascular disease, hypertension, major depressive disorder, and dementia without behavioral disturbance, the as-needed Klonopin order remained active beyond 14 days without a stop date. Similarly, another resident with diagnoses of edema, heart failure, depressive disorder, and anxiety had an as-needed Klonopin order for alcoholism that also lacked a specified duration or stop date, despite the pharmacist's recommendation. The DON confirmed in both cases that the orders were not updated as requested and remained in place for longer than 14 days.