Administration of Antidepressant Without Justified Diagnosis or Symptoms
Penalty
Summary
A deficiency occurred when a resident was administered an antidepressant medication, escitalopram, without a corresponding medical diagnosis or documented behavioral symptoms to justify its use. The resident was admitted with a diagnosis of anxiety disorder, but there was no diagnosis of depression documented in the Minimum Data Set (MDS), physician progress notes, or the problem list. The MDS assessment indicated no symptoms or behaviors of depression, and the depression screening was negative. Despite this, a physician's order was written for escitalopram with the indication of depression, citing 'verbalized sadness' as the target behavior, but the Treatment Administration History Record showed that this behavior did not occur during the review period. Further review of the Medication Regimen Review raised concerns about the lack of a documented indication for escitalopram, noting that depression was not listed in the resident's problem list and the history and physical stated the depression screening was negative. Interviews with facility staff, including the MDS Coordinator, a licensed nurse, and the DON, confirmed that the resident did not have a diagnosis of depression and that no target behaviors were observed or documented. The facility's policy on comprehensive care planning was reviewed, but a policy on unnecessary medications was requested and not provided.