Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper management and monitoring of psychotropic medications for multiple residents, resulting in deficiencies related to unnecessary medication use, lack of documentation, and failure to implement non-pharmacological interventions. For one resident with bipolar and depressive disorders, antipsychotic and antianxiety medications were administered without clear documentation of target behaviors, clinical rationale for medication duration beyond 14 days, or evidence that non-pharmacological interventions were attempted prior to medication administration. The care plan did not address all relevant diagnoses or specify the symptoms being treated, and staff interviews confirmed these omissions. Another resident was prescribed multiple psychotropic medications, including antianxiety, antipsychotic, and antidepressant drugs, without corresponding diagnoses documented in the medical record or care plan. The Director of Nursing Services acknowledged the lack of appropriate diagnoses and justification for these medications. Additionally, for several residents, as-needed psychotropic medications were ordered without required stop dates or re-evaluation, and pharmacist recommendations regarding medication duration and documentation were not acted upon in a timely manner. For residents on hospice or palliative care, as-needed psychotropic medications were ordered for periods exceeding regulatory limits without documented clinical justification or end dates. Medication administration records showed instances where medications were given without documentation of target behaviors or attempted non-pharmacological interventions. Staff interviews confirmed that monitoring for side effects and behaviors was not consistently ordered or documented, and that medication orders often lacked appropriate diagnoses or rationale.