Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use, specifically Risperidone, without a valid supporting diagnosis. The facility's policy requires all medications to be supported by a documented diagnosis or clinical rationale. Resident 45, who had severe cognitive impairment and a diagnosis of dementia, was observed to be calm, easily redirectable, and not exhibiting psychotic behaviors. Despite this, the resident had an active order for Risperidone for 'dementia with behavioral disturbances.' Staff interviews confirmed that the diagnosis of dementia alone was not appropriate for Risperidone use, and there was no documentation of specific behaviors or attempts at non-pharmacological interventions prior to starting the medication. Further review revealed that the medication was initiated at a previous assisted living facility due to reported behaviors, but the documentation lacked details of alternative interventions or a specific behavioral diagnosis. The facility's monthly psychotropic medication review process failed to identify the inappropriate diagnosis for the medication. Both the pharmacist and the Director of Nursing acknowledged that the diagnosis was not appropriate and that the oversight was not caught during routine audits.