Lack of Documented Indication and Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident received antipsychotic medication only with an appropriate indication and documented physician rationale, including unsuccessful attempts at nonpharmacological interventions and a risk versus benefit analysis for continued use. The resident in question had diagnoses of dementia, major depressive disorder, and Parkinson's disease, and was assessed as having moderately impaired cognition. The care plan documented the use of Seroquel, an antipsychotic, for depression and dementia, but did not specify the targeted behaviors for which the medication was prescribed. Additionally, the care plan directed staff to monitor for side effects and effectiveness, but lacked documentation of the specific behaviors being targeted by the medication. Physician orders for the antipsychotic medication listed varying diagnoses over time, including dementia with behaviors, major depressive disorder, and anxiety, without clear documentation supporting the indication for use. The facility's policy required clear and accurate physician orders, including diagnosis or indication for use, and periodic reassessment of the medication's effectiveness. However, the records did not show evidence of unsuccessful nonpharmacological interventions or a documented risk versus benefit analysis for the continued use of the antipsychotic medication, leading to the deficiency.