Failure to Ensure Psychotropic Medication Regimen Was Free from Unnecessary Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. Specifically, a resident with diagnoses of heart failure, anxiety, and respiratory failure was prescribed Hydroxyzine, a psychotropic medication, to be administered orally twice a day as needed for anxiety. The physician's order for Hydroxyzine did not include a required 14-day stop date, nor was there any documented rationale from the physician to justify the continuation of the medication beyond 14 days. Additionally, the resident's Medication Administration Record showed that Hydroxyzine was administered on four occasions, but there was no documentation in the progress notes indicating the resident's behaviors or any non-pharmacological interventions attempted prior to administering the medication. The Director of Nursing confirmed that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication, as required by facility policy and regulatory guidelines.