Failure to Ensure Resident Was Free from Unnecessary Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, depression, anxiety, and cerebral aneurysm, was not ensured to be free from unnecessary psychotropic medications. The resident was unable to complete the BIMS assessment, indicating significant cognitive impairment. Pharmacy medication regimen review in June recommended a gradual dose reduction (GDR) for several psychotropic medications, including Alprazolam, Gabapentin, and Quetiapine. Despite this recommendation, there was no evidence that the resident was re-evaluated by psychiatry after the pharmacy's suggestion, and the GDR was not implemented. Additionally, the Medical Director increased the resident's Seroquel dosage without documenting the rationale, the discussion regarding the pharmacy's GDR recommendation, or the use of non-pharmacological interventions prior to the medication increase. Progress notes did not reflect any attempt at non-pharmacological interventions when the resident exhibited agitation and aggression. Interviews with the DON and Medical Director confirmed that there was no documentation supporting the need for the additional medication or evidence of attempted non-pharmacological interventions, and the Medical Director acknowledged the lack of documentation and intervention as an error.