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 adequate monitoring and documentation for three residents. For one resident with diagnoses including psychosis, depression, anxiety, insomnia, and dementia, the facility did not monitor specific, measurable target behaviors related to the use of clonazepam, a psychotropic medication prescribed for anxiety. The medication order lacked a specific duration, and the manifestations of the behaviors being treated were not clearly defined, leading to inconsistent monitoring and documentation by nursing staff. Interviews with nursing staff confirmed that the absence of specific target behaviors and duration in the medication order could result in inaccurate assessments and prolonged, unnecessary use of the medication. Another resident with Alzheimer’s disease, dementia, and anxiety disorder was prescribed Ativan (lorazepam) as needed for anxiety. The orders for this medication did not specify a duration or clearly define the target behaviors for which the medication was to be administered. Consultant pharmacist recommendations to clarify the diagnosis and add a 14-day duration to the therapy were not acted upon or documented as addressed with the physician. The lack of follow-up on these recommendations and the absence of specific, measurable behaviors in the orders resulted in the resident being at risk for prolonged and unnecessary use of psychotropic medication. A third resident with Alzheimer’s disease, dementia, and depression was prescribed Remeron (mirtazapine) for depression. The facility failed to monitor and document the resident’s pulse rate and adverse effects on the medication administration record when the medication was administered. Nursing staff and administration confirmed that monitoring for adverse effects and pulse rate was required but not completed, which could lead to inaccurate assessment of the medication’s necessity and effectiveness. Facility policies required specific indications, manifestations, and monitoring for psychotropic medications, but these were not consistently followed for the residents involved.