Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation for the use of psychotropic medications for several residents. For two residents with diagnoses including dementia, anxiety disorder, and depression, the medical records did not identify target symptoms for prescribed antidepressants, nor was there evidence that the facility was monitoring these symptoms. Additionally, for another resident with dementia and a history of psychotic disturbance and depression, a PRN order for trazodone was issued without a stop date, and there was no documented rationale from the physician for this omission. Interviews with the facility administrator confirmed that some medications were prescribed with only a diagnosis and without identification of target symptoms, and that physicians did not always provide rationales for PRN psychotropic medications lacking stop dates. Review of facility policy indicated that PRN psychotropic medications should be limited to 14 days unless a rationale is documented, and that monitoring for efficacy and adverse consequences is required. These requirements were not met for the residents reviewed.