Failure to Ensure Proper Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to ensure appropriate management of psychotropic medications for three residents, specifically regarding gradual dose reduction (GDR), behavioral interventions, and proper documentation for continued use of PRN (as needed) medications. For one resident with severe cognitive impairment and a history of depression and anxiety, the facility continued PRN Ativan orders beyond the initial 90-day period without documented physician rationale for its ongoing use. The medication was administered multiple times over several months, and staff interviews confirmed the absence of required documentation supporting the continued PRN order. Another resident with diagnoses including dysthymic disorder and anxiety was maintained on two antidepressant medications, Citalopram and Bupropion, with dose adjustments over time. However, the medical record lacked documentation of a physician's response to a rationale for duplicative therapy and did not include evidence of a second GDR or justification for not reducing the medications further, as required by regulations. The DON acknowledged confusion regarding the medication orders and confirmed the absence of necessary documentation for dose reduction or rationale. A third resident with neurological and respiratory conditions was prescribed Trazodone for insomnia. Although a GDR was recommended and discussed in a psychotropic review meeting, the order to reduce the dose was not correctly implemented in the medical record. The DON admitted to documenting the recommendation in a progress note but failing to update the physician order for signature, resulting in the GDR not being carried out as intended.