Psychotropic Medication Administered Without Documented Diagnosis
Penalty
Summary
Surveyors identified that a resident was receiving trazodone HCL 50 mg via gastrostomy tube at bedtime for insomnia. Upon review of the resident's medical record, there was no documented diagnosis of insomnia to support the use of this psychotropic medication. The order for trazodone specified its use for insomnia, but the required corresponding diagnosis was absent from the resident's medical documentation. Interviews with the Director of Nursing (DON) confirmed that all medications should have an indication and a matching diagnosis in the medical record. The DON verified that there was no evidence of an insomnia diagnosis for the resident in question and acknowledged the lack of documentation supporting the medication order. This failure to ensure that psychotropic medications were only used to treat a specific, diagnosed, and documented condition constituted the deficiency.