Psychotropic Medication Prescribed Without Documented Indication
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs without adequate indications for use, as evidenced by the case of a resident who was prescribed a psychotropic medication without a documented diagnosis to support its use. Record review showed that the resident, who had severe cognitive impairment and a history of alcoholic cirrhosis with ascites and hepatitis C, was ordered buspirone for 'mood' without a corresponding psychiatric or mood disorder diagnosis documented in the medical record. The resident's care plan and medication orders included multiple psychotropic medications, but the required diagnosis for buspirone was not present. During an interview, the DON confirmed that psychotropic medications should have an associated diagnosis, and facility policy requires that such medications be used only when there is a specific, diagnosed, and documented condition. The lack of a documented indication for the use of buspirone in this resident's record constituted a failure to comply with facility policy and regulatory requirements regarding the use of psychotropic medications.