Failure to Assess and Address Unnecessary Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident with dementia was free from unnecessary use of antipsychotic medication. The resident was admitted with diagnoses including a stage four pressure ulcer and dementia, and was prescribed multiple psychoactive medications, including quetiapine, trazodone, venlafaxine, Namenda, and hydroxyzine. Despite the presence of symptoms and side effects associated with psychoactive medication use, as evidenced by increasing Abnormal Involuntary Movement Scale (AIMS) scores, the facility did not adequately assess the continued need for antipsychotic medication. The physician was notified of certain symptoms and reduced the dose of venlafaxine, but did not address the use of quetiapine. The Psychotropic Committee did not order additional gradual dose reductions (GDRs) or assess the appropriateness of continued antipsychotic use despite adverse side effects. Observations and staff interviews indicated that the resident did not exhibit negative behaviors or signs of distress, and staff reported that calling out behaviors had lessened and were not distressing to the resident. However, the facility relied on pharmacist reviews rather than conducting their own assessments for antipsychotic medication use. Facility leadership acknowledged that antipsychotic medication was prescribed to address calling out behaviors that were disturbing to others, but not distressing to the resident, and admitted that a comprehensive risk/benefit assessment should have been completed in light of the adverse side effects.