Failure to Ensure Psychotropic Medication Use Was Clinically Justified
Penalty
Summary
A resident was prescribed the antipsychotic medication Loxapine Succinate for a diagnosis of unspecified schizophrenia, according to her medication regimen and care plan. However, clinical record review and interviews revealed that there was no supporting documentation in the resident's medical record to confirm a diagnosis of schizophrenia. The facility's consulting psychiatric provider's progress notes only referenced a history of depression and did not mention schizophrenia or provide justification for the use of an antipsychotic. The care plan addressing psychotropic medication use did not include any target behaviors to support the indication for antipsychotic use, and behavior monitoring was limited to tracking if the resident was withdrawn. The resident herself reported a history of depression following her mother's death and denied ever experiencing symptoms such as delusions, hallucinations, or disorganized thinking. Interviews with facility staff confirmed the absence of documentation supporting a schizophrenia diagnosis and the lack of monitoring for specific target behaviors related to antipsychotic use. As a result, the facility failed to ensure the resident's medication regimen was free from potentially unnecessary psychotropic medication, as required by regulation.