Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
Staff administered Haldol, an antipsychotic medication, to a resident with severe dementia and agitation on multiple occasions without a qualifying diagnosis and without first attempting other interventions. The resident's care plan indicated behavioral issues such as anger, resistance to care, wandering, and exit-seeking, with interventions including medication administration, monitoring for side effects, and psychiatric referral. Despite these interventions, the resident received Haldol injections repeatedly, as documented in the Medication Administration Record and nursing progress notes, often in response to agitation, verbal threats, or physical aggression. The documentation revealed that staff did not consistently record the reasons for administering Haldol, and in at least one instance, there was no nursing progress note to justify the use of the medication. Interviews with facility staff, including the Social Services Assistant and Unit Manager, indicated that the resident's behaviors were attributed to his dissatisfaction with being at the facility, and that medication should not have been the first intervention. The Unit Manager specifically stated that staff were expected to try other interventions before resorting to Haldol, and that medication should not be the initial response to behavioral issues. The Physician Assistant who ordered the Haldol stated it was intended for severe agitation and that suicidal threats alone did not warrant its use. The PA also acknowledged that staff could interpret 'extreme agitation' subjectively, potentially leading to inconsistent administration of the medication. The repeated use of Haldol without documented attempts at alternative interventions and without a clear qualifying diagnosis constituted the deficiency identified by surveyors.