Failure to Complete Required Evaluation Before Antipsychotic Administration
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment prior to the administration of an antipsychotic medication. Record review showed that the resident, who had diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a traumatic subdural hemorrhage, was not evaluated before being given Haldol Decanoate for aggressive behavior. The resident's admission MDS indicated severe cognitive impairment with no behavioral symptoms or indicators of psychosis, and there was no documentation of an evaluation prior to the initiation of the antipsychotic. Progress notes confirmed that the antipsychotic was ordered and administered without a prior psychiatric evaluation, and the care plan was updated to reflect the use of Haldol for agitation. Interviews with facility staff, including a physician assistant, LVN, and the DON, confirmed that an evaluation should have been completed before administering the medication, and that no such evaluation was documented. The facility's policy also required an evaluation and documentation prior to the use of psychotropic medications, which was not followed in this case.