Failure to Ensure Medication Regimens Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from potentially unnecessary psychotropic medications for two residents. For one resident with diagnoses including high blood pressure, dementia, and chronic pain, the consultant pharmacist identified that an order for Seroquel, an antipsychotic medication, lacked an appropriate diagnosis and requested physician review. However, there was no documentation that the physician addressed or signed off on this recommendation, as required by facility policy. For another resident with anxiety, depression, and Bipolar Disorder, the clinical record showed multiple psychotropic medications prescribed, including Diazepam, Lorazepam, Sertraline, and Trazodone. The facility was unable to provide documentation that the required monthly medication regimen reviews (MRRs) were completed by the consultant pharmacist for two specific months. The DON confirmed the absence of this documentation and acknowledged the failure to ensure the medication regimens were free from potentially unnecessary psychotropic medications.