Lack of Physician Documentation for Antipsychotic Use in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with dementia and severely impaired cognition received antipsychotic medications only with appropriate physician documentation and rationale. The resident, who also had diagnoses of repeated falls, muscle weakness, and Parkinson's disease, was prescribed Haloperidol for hallucinations and Seroquel for anxiousness. The medical record and care plan indicated ongoing use of these medications, with monthly pharmacist reviews and physician oversight of recommendations. However, the facility was unable to provide documentation from the physician that included a clear rationale for the continued use of antipsychotic medications, evidence of multiple unsuccessful attempts at nonpharmacological interventions, or an assessment of the risks versus benefits for this resident. Additionally, the consent form for psychoactive medication therapy was unsigned and lacked the required physician documentation. Interviews confirmed that the facility used preprinted consent forms and that the resident was on hospice services, with the family requesting continuation of the antipsychotic medication. The facility's policy required that psychotropic drugs be used only when necessary for specific conditions and not for staff convenience or discipline, and that residents or their representatives have the right to refuse such treatment. Despite these requirements, the necessary physician documentation supporting the use of antipsychotic medication for this resident was not present.