Failure to Monitor and Document Psychotropic Medication Use and Nonpharmacological Interventions
Penalty
Summary
Surveyors identified deficiencies related to the use and monitoring of psychotropic medications for multiple residents with diagnoses such as anxiety, depression, dementia with agitation, and insomnia. Physician orders for these residents included various psychotropic medications, such as lorazepam, quetiapine, bupropion, buspirone, venlafaxine, fluoxetine, aripiprazole, and trazodone. Despite these orders, the facility failed to ensure that resident-specific targeted behaviors were identified, monitored, and documented to assess the effectiveness and necessity of these medications. Care plans and CNA Kardexes often lacked documentation of the specific behaviors that triggered medication use, as well as nonpharmacological interventions to address these behaviors. Interviews with staff, including CNAs, medication technicians, LPNs, and a social worker, revealed a lack of awareness and training regarding behavior monitoring and the use of nonpharmacological interventions. Staff described resident behaviors such as agitation, restlessness, yelling, and frustration, but these were not consistently documented in care plans or the electronic health record. In several cases, staff relied on as-needed medication administration without clear documentation of the behaviors leading to medication use or the effectiveness of the interventions. Additionally, staff reported that they would only document behaviors in progress notes if they were unusual, despite some residents exhibiting daily symptoms. Facility policies required the development and implementation of baseline care plans that include person-centered interventions and the use of nonpharmacological approaches before psychotropic medications are used. However, the survey found that these policies were not followed, as evidenced by the lack of individualized behavior monitoring, absence of nonpharmacological interventions in care plans, and insufficient documentation of the rationale for psychotropic medication use. This resulted in the facility not meeting professional standards of quality care for residents receiving psychotropic medications.