Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
A resident with severe cognitive impairment and a history of cerebral infarction, dementia, and behavioral disturbances was prescribed psychotropic medications, specifically Haldol (haloperidol) and Olanzapine (Zyprexa), without an adequate psychiatric diagnosis to justify their use. The medications were initiated and increased over time, despite the absence of documented psychiatric conditions such as schizophrenia or bipolar disorder. The care plan did not include a mental health diagnosis or PASARR documentation to support the use of antipsychotic medications, and non-pharmacological interventions were not developed or implemented prior to the administration of these drugs. Staff interviews and record reviews revealed that the resident began experiencing increased sedation, weight loss, decreased ability to communicate, and multiple falls after the initiation of the psychotropic medications. Documentation showed that Haldol was administered even after the resident was no longer agitated, and there was a lack of evidence that non-pharmacological interventions were attempted before resorting to medication. Progress notes and medication administration records indicated that PRN Haldol was given multiple times without proper documentation of the behaviors leading to its use or the effectiveness of alternative interventions. The resident's guardian was not adequately informed about medication changes, and consent forms lacked critical information such as dosage, route, frequency, and expected benefits or side effects. Observations and interviews with staff highlighted issues of short staffing, lack of individualized care, and insufficient monitoring of the resident's condition, including hydration and nutritional status. The resident was found to be lethargic, unable to eat or drink, and had significant weight loss and dehydration, ultimately requiring transfer to a hospital. The facility's interdisciplinary team and medical director were not fully aware of the extent of the psychotropic medication regimen, and there was a failure to ensure appropriate oversight and monitoring of the resident's response to these medications.
Removal Plan
- Obtain an order from the facility Psychiatrist/Resident's Physician to discontinue medication.
- Add 1:1 for safety of self and other residents due to increased aggression.
- Complete a chart audit on all residents currently prescribed an antipsychotic medication to ensure an adequate indication for use and appropriate documentation is present to support use of the medication.
- Audit all residents who receive antipsychotic medication.