Lack of Documentation and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed to residents had appropriate documentation for medical use, including clear indications, re-evaluation dates, and duration of use. For one resident with diagnoses including dysphagia, tremors, dementia, osteoarthritis, and adult failure to thrive, a physician order for Lorazepam as needed (PRN) for anxiety did not specify a re-evaluation or duration date. The medication was administered daily over multiple days, and the order was only later changed to include a 14-day duration. For another resident with encephalopathy, hypotension, Alzheimer's disease, and atrial fibrillation, a PRN order for Haloperidol for agitation also lacked a re-evaluation or duration date, and the resident did not have a documented medical diagnosis supporting the use of this antipsychotic. The medication was administered on multiple days across two months. A pharmacy medication regimen review recommended re-evaluation and the addition of a stop date for the Haloperidol order, but this recommendation was not reviewed or signed by the physician until the resident was about to be discharged. The Director of Nursing confirmed that both residents' PRN psychotropic medication orders lacked required re-evaluation and duration dates, and that the medical record did not show adequate indications for the use of Haloperidol. Facility policy required that each resident's medication regimen be managed and monitored for dose, duration, indication, and clinical need, but these requirements were not met for the residents reviewed.