Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure proper monitoring and documentation for residents prescribed antipsychotic drugs. In several cases, standing orders for injectable antipsychotics, such as Haldol, were implemented without documentation of nonpharmacological interventions being attempted prior to administration. For example, a resident with bipolar disorder, anxiety disorder, and substance use disorder had a standing order for Haldol IM if oral psychotropic medications were refused, but the medical record and facility policy did not specify or document any nonpharmacological interventions prior to use. Staff interviews confirmed the absence of such documentation and the lack of evidence that alternatives were considered before administering the medication. Additionally, the facility did not consistently monitor for orthostatic hypotension in residents receiving antipsychotic medications, as required by physician orders and facility policy. Multiple residents on medications such as Seroquel, Clozaril, and risperidone had orders for regular orthostatic blood pressure monitoring, but records showed either identical blood pressure readings for different positions (lying, sitting, standing), or readings taken hours apart, which is not consistent with proper orthostatic assessment. In some cases, significant drops in blood pressure were not reassessed or reported to the physician, and there was no documentation of resident assessment following abnormal readings. Staff interviews revealed a lack of understanding regarding the parameters for orthostatic hypotension and the appropriate steps to take when abnormal readings were identified. The facility's policies required monitoring for side effects and adverse consequences of antipsychotic medications, including orthostatic hypotension, but these were not followed in practice. Documentation failures included not recording nonpharmacological interventions, not obtaining or documenting informed consent with specific medication details, and not accurately or consistently monitoring and documenting orthostatic blood pressure as ordered. These deficiencies were verified by staff and the DON during interviews and record reviews.