Failure to Document Non-Pharmacological Interventions and Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications by not documenting the use or evaluation of non-pharmacological interventions (NPI) prior to initiating these medications. For both residents, there was no evidence in the medical records that behavioral, environmental, or person-centered approaches were attempted or monitored before and during the administration of psychotropic drugs, including duloxetine, amitriptyline, citalopram, and temazepam. The care plans referenced the need for non-drug interventions, but there was no documentation that these were implemented or evaluated in practice. For one resident with major depressive disorder, orders for duloxetine and amitriptyline were initiated without any documented trial or assessment of NPI, and the care plan did not address non-pharmacological strategies for the ongoing use of these medications. Similarly, another resident with insomnia and depression was started on citalopram and temazepam without documentation of attempted or evaluated NPI, despite the care plan instructing staff to assess and modify environmental or behavioral factors before starting hypnotic therapy. In both cases, the Director of Nursing confirmed the absence of documentation regarding the implementation and monitoring of NPI alongside the continued use of psychotropic medications. Additionally, for the resident receiving temazepam as a PRN medication, there was no documented rationale from the prescriber for extending the PRN order beyond 14 days, as required by facility policy. The facility's own policy mandates that psychotropic medications should not be used without first attempting non-drug interventions and that PRN orders for such medications must be justified and time-limited unless a rationale is documented. These documentation failures were confirmed during interviews and record reviews with facility leadership.