Lack of Documentation for Psychotropic Medication Dose Increase
Penalty
Summary
A deficiency was identified when a resident's medication regimen included an increase in the dose of a psychotropic medication, Lorazepam, without corresponding documentation in the medical record to explain the reason for the dosage change. The resident, who was enrolled in hospice care, had their Lorazepam regimen adjusted multiple times over a short period, including an increase in the bedtime dose. Although a psychiatric nurse practitioner initially recommended Lorazepam and the attending physician made subsequent changes, there was no documented evaluation or justification for the increase in the psychotropic medication dose on the date it was changed. Medical record review revealed that while provider notes and nursing documentation addressed some medication changes, there was a lack of documentation specifically regarding the rationale for the increased bedtime dose. The Director of Nursing confirmed that no further evaluation or provider documentation was available to support the psychotropic dose increase. This failure to document the clinical reasoning for the medication adjustment resulted in the facility not ensuring the resident's medication regimen was free from unnecessary psychotropic medication.