Failure to Justify and Limit Psychotropic Medication Use
Penalty
Summary
The facility failed to provide adequate documentation to justify the continued use of psychotropic medications for two residents. For one resident admitted in September 2024, the consultant pharmacist identified several medications, including Risperidone, Lorazepam, Fluoxetine, and Trazodone, as potential contributors to a recent fall. The pharmacist recommended that the physician evaluate these medications for their role in the fall and document a risk versus benefit assessment if therapy was to continue. The physician initially responded with 'Thank you. No change.' and later, after further inquiry, noted that the medications were being titrated for dementia and for safety/dignity, but did not provide a specific assessment or justification as recommended. For another resident, there was a provider order for Lorazepam 0.5 mg orally as needed for anxiety disorder, with no stop date, exceeding the required 14-day limit for PRN psychotropic medications. As of the date of review, the medical record did not contain evidence of clinical rationale to continue the medication beyond 14 days. These findings were confirmed through record review and interviews with the Director of Nursing Services.