Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraints
Penalty
Summary
Facility staff failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as well as to limit PRN psychotropic medications to 14 days. For one resident reviewed for discharge, the medical record showed ongoing administration of quetiapine for sundowning and lorazepam as needed for anxiety, with both medications continued for several months. The informed consent for psychotropic use was signed on the day of admission, stating that all nonpharmacological interventions had been exhausted, but there was no evidence that such interventions were attempted or documented prior to medication administration. Physician orders for the resident included lorazepam PRN without a 14-day stop date and quetiapine with an increased dosage for a diagnosis that was not appropriate. There was no documentation of behavior monitoring or attempts at gradual dose reduction for these medications. The psychiatric NP documented continued use of quetiapine for behavior modification, but behavior notes did not reflect monitoring of the targeted behaviors. The medication administration record showed multiple administrations of lorazepam by the same RN, with no documentation of the reasons for administration or nonpharmacological interventions attempted beforehand. Interviews with facility staff, including the attending physician, RN, and DON, confirmed that documentation was lacking regarding the behaviors leading to medication use and the use of nonpharmacological interventions. The DON acknowledged that the consent form was not appropriate and that behavior monitoring and documentation were not adequately performed. The staff also recognized that the PRN order for lorazepam should have included a 14-day stop date, and that the diagnosis for quetiapine was not appropriate.