Failure to Ensure Approved Indications for Psychotropic Medication Use
Penalty
Summary
Surveyors identified that the facility failed to ensure psychotropic medications were prescribed with approved indications for use for two of five sampled residents. Facility policy requires that antipsychotic medications be used only for specific, documented conditions and after non-pharmacological interventions have been attempted, except in emergencies. The policy also mandates that medications such as antipsychotics and antidepressants be prescribed only when necessary to treat specific conditions, and that diagnoses alone do not warrant their use without supporting behavioral symptoms and documentation. For one resident with diagnoses including neurocognitive disorder with Lewy bodies, Alzheimer's disease, anxiety disorder, and insomnia, the medical record showed the use of mirtazapine for depression and insomnia, and Seroquel for dementia-related symptoms. However, there was no diagnosis of depression documented in the resident's medical record or on the active diagnosis sheet, despite the ongoing administration of mirtazapine for that indication. Behavioral monitoring documented symptoms such as sadness, tearfulness, wandering, and anxiety, with interventions attempted but with mixed or unchanged results. Another resident with unspecified dementia, bipolar disorder, and anxiety disorder was prescribed Ambien for insomnia, Klonopin for anxiety, Remeron for bipolar disorder, and Seroquel for bipolar disorder. The care plan referenced the use of psychotropic medications for bipolar disorder and insomnia, but there was no diagnosis of insomnia documented in the medical record or on the active diagnosis sheet, despite the administration of Ambien for that purpose. Behavioral monitoring noted episodes of frustration and verbal aggression, with interventions resulting in either improvement or no change.