Failure to Review and Individualize Psychotropic Medication Regimen
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary psychotropic medication. Clinical record review revealed that a resident had active physician orders for Alprazolam, including a PRN (as needed) dose of 1 mg every eight hours with a 180-day stop date, and a scheduled dose of 0.5 mg three times daily. If administered as ordered, the resident could have received up to 4.5 mg of Alprazolam per day, exceeding the usual maximum adult dose of 4 mg per day. Review of the medication administration records showed that the PRN dose was administered on multiple occasions, but never more than once per day, and not daily. The pattern of administration indicated that the PRN dose was consistently given between 10:00 AM and 12:00 PM on most occasions. Despite this pattern, the facility did not identify or address the resident's consistent need for the PRN antianxiety medication at a specific time of day in the care plan. Additionally, there was insufficient evidence that the resident required a dose exceeding the recommended daily maximum, or that the 180-day stop date met the regulatory requirement for physician review at 14 days. Interviews with facility leadership confirmed these findings, and the care plan lacked individualized interventions based on the resident's medication use pattern.