Failure to Ensure Proper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications for two residents. For one resident with dementia, depressive disorder, and anxiety disorder, Lorazepam was ordered and administered as needed (PRN) over an extended period, with orders being renewed continuously from March through June. The medication was given almost daily, sometimes twice a day, without a documented 14-day limitation for PRN use as required. After an initial psychiatric evaluation in April noting the medication's effectiveness, there was no further documented evaluation or rationale for the continued use of Lorazepam, despite its frequent administration. For another resident, a psychotropic medication (Rexulti) was ordered for behavior management related to dementia. However, review of the resident's Minimum Data Set (MDS) and treatment administration records over several months showed no documented behavioral symptoms or incidents that would justify the use of such medication. Staff interviews confirmed that behaviors were not observed or documented during this period, and the psychiatric nurse practitioner acknowledged that the order was based on a single observation of agitation and confusion, with no subsequent behavioral incidents recorded. These findings demonstrate that the facility did not ensure psychotropic medications were prescribed and administered in accordance with regulatory requirements, including proper documentation, ongoing evaluation, and justification for continued use. The lack of appropriate monitoring and documentation resulted in residents receiving unnecessary medications or medications without the required oversight.