Failure to Ensure Drug Regimens Are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications, as evidenced by the lack of appropriate diagnoses and monitoring for several residents receiving psychotropic and psychoactive drugs. For one resident, Zyprexa was prescribed for agitation without a documented diagnosis of agitation or any behavioral disturbances, and the care plan did not address agitation or anxiety. The resident's medical records and interviews with the responsible party confirmed the absence of aggressive behaviors or a history of agitation, yet the medication continued to be administered without proper justification or review. Another resident was prescribed Remeron for depression and Buspirone for anxiety, but there was no evidence in the medical record of monitoring for behaviors or side effects associated with these medications. The care plan indicated a risk for side effects and called for monitoring, but this was not carried out. The DON acknowledged that the required monitoring was not performed, which was contrary to facility policy and expectations for medication management. A third resident received multiple psychoactive medications, including Olanzapine for agitation and Divalproex Sodium for mood, without documented diagnoses to support their use. The care plan referenced the use of these medications for agitation and mood, but the clinical record did not contain corresponding diagnoses. Facility policy required that antipsychotic medications only be used for specific, documented conditions, and that all medications be clinically indicated, but this was not followed in these cases.