Unnecessary Use of Antipsychotic Medication Without Proper Indication
Penalty
Summary
The facility did not ensure that a resident was free from unnecessary psychotropic medications, as required by policy and regulation. One resident with a diagnosis of Alzheimer's disease with late onset was prescribed Olanzapine, an antipsychotic medication, without an appropriate clinical indication documented in the medical record. The facility's policy states that psychotropic medications should only be used when non-pharmacological interventions are clinically contraindicated and when there is a documented, adequate indication for use. In this case, the physician order listed Alzheimer's disease with late onset as the reason for the antipsychotic, which is not an appropriate indication for such medication. During interviews, the prescribing physician assistant stated that the medication was given due to the resident's severe psychosis, impulsivity, and lack of safety awareness, describing behaviors such as wandering and attempting to stand without assistance. However, these behaviors are common in individuals with Alzheimer's disease and do not necessarily justify the use of antipsychotic medication. The facility failed to document persistent and harmful behaviors or evidence that non-pharmacological interventions were attempted or clinically contraindicated prior to initiating the antipsychotic. As a result, the resident received an unnecessary psychotropic medication without proper justification.