Failure to Ensure Proper Use and Review of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were used only for residents with specific, diagnosed, and documented conditions. In two cases, residents were prescribed antipsychotic medications (Quetiapine Fumarate and Risperdal) for diagnoses such as bipolar disorder, but review of their medical records and histories did not confirm the presence of these diagnoses. Staff interviews revealed uncertainty about the residents' diagnoses, and facility records, including histories and physicals, did not support the documented indications for the medications. Consent forms and medication orders listed diagnoses that were not substantiated in the residents' medical histories at the time of review. Additionally, the facility failed to obtain a physician-signed gradual dose reduction (GDR) for five psychotropic medications prescribed to another resident. Although the consultant pharmacist made recommendations for GDR, there was no evidence of physician review or signature on the relevant documentation. Staff interviews indicated that nurses were not involved in reviewing medications for possible dose reductions, and the process for obtaining physician approval for GDRs was not consistently followed, as evidenced by incomplete and unsigned forms.