Failure to Document Non-Pharmacological Interventions and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. According to facility policy, psychotropic medications should only be administered when non-pharmacological interventions are clinically ineffective, and their use must be supported by a specific, diagnosed, and documented condition. For one resident with diagnoses including a humerus fracture, protein-calorie malnutrition, and diabetes mellitus, the clinical record showed the use of Lorazepam and Duloxetine, both psychotropic medications. The resident received Lorazepam as needed for anxiety multiple times, but there was no documentation of non-pharmacological interventions attempted prior to administration. Additionally, the clinical record lacked evidence of side effect or behavior monitoring related to the use of psychotropic medications, as required by facility policy. The care plan indicated the need to monitor for side effects and effectiveness every shift, but this was not documented. The DON confirmed during an interview that there was no documentation of non-pharmacological interventions prior to administering as-needed psychotropic medication, nor was there monitoring in place for side effects or behaviors associated with the medication use.