Failure to Assess Underlying Causes Before Psychotropic Medication Use
Penalty
Summary
The facility failed to assess and evaluate the underlying causes of behavioral symptoms in a resident prior to initiating or continuing psychotropic medications, as required by both facility policy and regulatory standards. The resident in question had a history of cognitive impairment, dementia, and pain, and was admitted with multiple diagnoses including a cognitive communication deficit and a history of hip replacement. Despite documented moderate pain and behavioral symptoms, there was no evidence that staff consistently attempted non-pharmacological interventions or thoroughly assessed for underlying causes, such as pain, before administering psychotropic medications. Record reviews revealed that the resident experienced ongoing pain, with frequent reports of high pain scores and observable nonverbal indicators such as restlessness, facial expressions, and protective postures. Staff administered PRN pain medications, but documentation showed these were often ineffective, and there was a lack of follow-up or additional interventions to address the resident's pain. Behavioral incidents, including physical and verbal outbursts, were managed with psychotropic medications like Ativan and Seroquel, but there was no evidence that staff attempted non-pharmacological interventions or notified the provider about the resident's ongoing pain prior to obtaining these medication orders. Interviews with staff and the DON confirmed that the resident's behaviors could have been related to uncontrolled pain and that expected protocols, such as assessment during behavioral episodes, implementation of non-pharmacological interventions, and physician notification, were not followed. The facility's failure to identify and address the underlying causes of the resident's behaviors, particularly pain, led to the unnecessary use of psychotropic medications without adequate attempts at alternative interventions.