Unnecessary Antipsychotic Administration Without Indication or Documentation
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the administration of Haldol (an antipsychotic) without an adequate indication for use. The resident in question had diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a history of traumatic subdural hemorrhage. Despite the absence of documented behavioral symptoms or psychosis, a new order for Haldol Decanoate 50mg IM monthly was initiated for 'aggression behavior,' but there was no supporting documentation of such behaviors in the resident’s records. Review of the resident’s medical records revealed inconsistencies and lack of clarity regarding the Haldol order. The medication was administered on at least two occasions, but the order was not consistently present on the Medication Administration Record (MAR), and there was no documented indication for use from the time the order was written through several months afterward. Interviews with facility staff, including the prescribing provider and the DON, revealed confusion about the origin of the order, with the primary physician denying knowledge of or responsibility for the prescription. Staff also confirmed that the required behavioral assessments and psychiatric evaluations were not completed prior to administration, and that the resident did not exhibit behaviors warranting antipsychotic use. Additionally, the facility’s policy required informed consent and documentation of risks, benefits, and alternatives prior to initiating psychotropic medications, especially those with black box warnings. While a consent form was eventually signed by the resident’s representative, this occurred months after the initial administration of the medication. The lack of proper documentation, absence of a clear clinical indication, and failure to follow facility policy led to the administration of an unnecessary antipsychotic medication to a resident.