Failure to Ensure Proper Use and Documentation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medications unless medically necessary, as evidenced by the lack of gradual dose reductions (GDR) and improper management of PRN (as needed) psychotropic medication orders. For two residents with diagnoses including depressive disorders and dementia, the facility did not attempt GDRs for medications such as fluoxetine, divalproex, buspirone, and sertraline, despite pharmacist recommendations. In both cases, the medical records lacked documentation from the physician providing a rationale for not attempting GDRs, and the relevant forms were either unsigned or incomplete. Additionally, two other residents received PRN psychotropic medications, such as lorazepam and Ativan, without proper documentation of the rationale for continued use beyond 14 days or an indication of the duration of the PRN order. In one case, the medication regimen review form for lorazepam was incomplete, with the anticipated duration of use left blank, even though the physician agreed with the recommendation. In another case, the medical record for Ativan did not include a documented rationale or duration for the PRN order. These deficiencies were confirmed through record reviews and interviews with the DON and Regional Nurse Consultant, who acknowledged the lack of GDR attempts, missing physician rationales, and incomplete documentation for PRN psychotropic medications. The findings indicate that the facility did not follow required protocols for the use and documentation of psychotropic medications for several residents.