Psychotropic Medication Ordered Without Approved Diagnosis
Penalty
Summary
The facility failed to ensure that a psychotropic medication, Aripiprazole (an antipsychotic), was ordered for an approved diagnosis for one resident. Medical record review showed that the resident, who had diagnoses including abdominal pain, spinal stenosis, gastritis, and malnutrition, was admitted with moderate cognitive impairment. The active physician order listed Aripiprazole to be administered daily for hypotension, which is not an approved indication for this medication. Staff interviews confirmed that Aripiprazole is not used to treat hypotension and that the order lacked an appropriate diagnosis. Although hospital documentation included a diagnosis of mood disorder, this was not reflected in the facility's electronic medical record. The facility's policy requires that medications be documented to treat a specific condition present in the medical record, which was not followed in this case.