Antipsychotic Medications Prescribed Without Appropriate Clinical Diagnosis
Penalty
Summary
The facility failed to ensure that antipsychotic medications were prescribed with appropriate, clinically documented diagnoses for one of six residents reviewed. A resident was admitted with diagnoses including Major Depressive Disorder, Single Episode, Unspecified, but the medical record did not indicate any other psychiatric or mood disorders. Despite this, the resident received multiple orders for antipsychotic medications, including Olanzapine and Haloperidol, for various indications such as mood, psychosis, and major depressive disorder. The Minimum Data Set (MDS) assessments consistently listed only depression as a psychiatric diagnosis, with no documentation of psychosis or other psychiatric conditions that would warrant the use of antipsychotic medications. Interviews with facility staff revealed that the pharmacist did not consistently verify that a specific supporting diagnosis was present for each medication, relying instead on the fact that medications can be used for multiple conditions. The DON described a process where the physician provides a diagnosis with each new medication order, and nurses enter this information into the electronic health record, which prompts for an associated diagnosis. Orders are reviewed daily, and the MDS nurse and consultant pharmacist are responsible for verifying the accuracy of diagnoses, particularly for psychotropic medications. However, the documentation reviewed did not support the use of antipsychotic medications for the resident in question.