Failure to Ensure Unnecessary Psychotropic Medications Are Avoided
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications for two of five residents reviewed. For one resident with a diagnosis of schizophrenia, the medical record showed ongoing prescriptions for antipsychotic and antianxiety medications, but the facility could not provide documentation of a required risk-benefit statement signed by the physician or evidence supporting a gradual dose reduction (GDR) as indicated in the assessment. Additionally, a physician order for PRN lorazepam lacked a stop date, and the interim DON confirmed that the GDR documentation could not be located and that the psychotropic medication review process was still being organized. For another resident with a diagnosis of depression, records indicated the ongoing use of an antidepressant without any attempt at GDR or documentation that a reduction was clinically contraindicated. The medication regimen review did not include a rationale for continuing the current dose, and the interim DON confirmed that no GDR was attempted and no rationale was documented. These findings demonstrate lapses in the facility's processes for monitoring and documenting the use of psychotropic medications.