Failure to Document Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three out of five sampled residents were free from unnecessary psychotropic medications, as required. For each of these residents, psychotropic medications were administered without documented evidence that non-pharmacological interventions were attempted or considered prior to medication use. Specifically, one resident with schizoaffective and bipolar disorder received Lexapro, Depakote, and Seroquel for behavioral symptoms, but there was no documentation of non-drug interventions such as redirection, activities, or emotional support. Staff confirmed that these interventions were not documented, and previous documentation requirements had been removed by the prior DON. Another resident with dementia and depression was prescribed mirtazapine for poor meal intake, yet there was no evidence that non-drug interventions like offering appetizing food or emotional support were tried before starting the medication. A third resident with anxiety and schizophrenia received risperidone and Depakote for behavioral symptoms, but again, there was no documentation of non-drug interventions being attempted or that such interventions were contraindicated. Staff interviews confirmed that while non-drug interventions may have been used, they were not documented in the residents' records. The facility's own policy requires that non-drug approaches be attempted and documented before psychotropic medications are used.