Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraints
Penalty
Summary
Facility staff failed to prevent the use of unnecessary psychotropic medications and did not ensure residents were free from chemical restraints. For one resident with moderate cognitive impairment and multiple diagnoses, including dementia and Parkinson's disease, staff administered PRN Lorazepam for anxiety over an extended period without proper documentation of the indication for use or a specified duration of therapy. The medication was given repeatedly for several months, and there was no provider documentation justifying the continued use beyond 14 days, as required. In another case, staff administered the antipsychotic Seroquel to a resident with a history of dementia, PTSD, and other medical conditions. The clinical record showed the medication was prescribed for dementia and PTSD, but the psychiatric assessment did not document symptoms of psychosis or behaviors that would warrant antipsychotic use. Additionally, Seroquel is not FDA-approved for the treatment of dementia or PTSD. The facility was unable to provide adequate documentation supporting the rationale for the prescription.