Antipsychotic Medication Prescribed Without Supported Diagnosis
Penalty
Summary
The facility failed to ensure that the use of antipsychotic medication for a resident was based on a clinically supported diagnosis. Record review showed that a resident with diagnoses including bipolar disorder, psychoactive substance abuse, and nicotine dependence was prescribed Venlafaxine HCL for depression and Quetiapine Fumarate for depression. However, the admission MDS assessment indicated the resident was cognitively intact and had no symptoms of depression. Further, there was no current diagnosis of depression documented in the medical record, nor was there a care plan related to depression. The facility's own policy requires that psychoactive medication orders be supported by appropriate clinical diagnoses or behavioral symptoms, which was not followed in this case.