Failure to Attempt and Document Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that less restrictive alternatives were attempted and documented prior to administering additional antipsychotic medication for two residents reviewed for unnecessary medications. In one case, a medical director ordered an increased dose of Seroquel for a resident exhibiting agitation and aggression, but there was no documentation of non-pharmacological interventions being attempted before the medication increase. The medical record and staff interviews confirmed that no such interventions were provided or documented, and the medical director acknowledged the omission of both rationale and non-pharmacological orders. In another case, monthly pharmacy reviews identified irregularities in the medication regimen of a resident prescribed Seroquel, Lexapro, and Haldol. The pharmacist recommended evaluating the eligibility for gradual dose reduction (GDR) and monitoring for symptoms, but the recommended adjustments to the medications were not addressed for several months. The DON confirmed that while pharmacy reviews and recommendations were made, there was no documentation to show that non-pharmacological interventions were provided to the resident during this period.