Antipsychotic Medication Administered Without Proper Indication
Penalty
Summary
The facility failed to ensure that a resident was free from the use of an antipsychotic medication without a proper physician-documented indication. The resident in question had diagnoses of neurocognitive disorder with Lewy bodies and a cognitive communication deficit, with severely impaired cognition and a need for maximum or full staff assistance with activities of daily living. Despite these conditions, the resident was administered quetiapine, an antipsychotic, daily as ordered by the physician for a mood disorder. The care plan included a Black Box Warning for quetiapine, noting increased risk of death in elderly patients with dementia-related psychosis and that the medication was not approved for such use. The facility's policy required that psychotropic medications only be used for specific, documented conditions, and that antipsychotics generally be reserved for certain diagnoses, none of which were present in this case. Record review showed that the resident's electronic medical record and medication administration record lacked documentation of any abnormal behaviors or a written physician rationale for the use of quetiapine without an approved indication. The pharmacist had provided recommendations for the physician to indicate the reason for use, but the physician did not document a rationale. Additionally, psychiatry had not assessed the resident. These actions and omissions resulted in the use of an antipsychotic medication without proper justification, contrary to facility policy and regulatory requirements.