Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medication use by not meeting required conditions for prescribing and monitoring these medications. For one resident with dementia and mood disturbance, Seroquel was prescribed for 'psychosis manifested by sudden anger outburst' without documentation that the symptoms were due to mania, psychosis, or delusions, or that the behaviors presented a danger to the resident or others. There was also no evidence that the symptoms were not due to a medical condition expected to resolve, or that non-pharmacological interventions had been attempted and found ineffective. The resident’s family member, who was the primary decision maker, refused a gradual dose reduction despite recommendations from the pharmacist and nurse practitioner, and staff interviews indicated the resident’s behaviors were limited to yelling or screaming, with no significant aggression or danger noted. Another resident with cognitive and coordination deficits was prescribed Ativan on an as-needed basis for anxiety manifested by agitation and verbal aggression. The physician’s order required that non-pharmacological interventions be attempted prior to medication administration. However, documentation showed that Ativan was administered without any record of such interventions being tried first, contrary to the order and facility policy. The DON confirmed that non-pharmacological approaches should have been attempted and documented before medicating the resident. A third resident with generalized anxiety disorder and bipolar disorder was prescribed Clonazepam for anxiety. Behavioral monitoring was not initiated at the start of medication administration, and for several weeks, there was no documentation of behavioral assessments prior to giving the medication. The RN and DON both acknowledged that behavioral monitoring should have started with the initiation of Clonazepam, and that the lack of documentation meant the medication was being administered without an indication. Facility policy required monitoring for effectiveness and adverse consequences of psychotropic medications, which was not followed in this case.