Failure to Document Indications for Psychotropic and Sedative Medications
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs by not providing adequate indications of use for certain medications based on the residents' diagnoses. For three residents reviewed, physician orders included medications such as Ativan, Trazadone, Hydroxyzine, and Lorazepam prescribed for conditions like agitation, anxiety, and insomnia. However, record reviews revealed that the corresponding diagnoses for agitation and insomnia were not documented in the residents' electronic health records (EHRs). For example, one resident was prescribed Ativan for agitated behavior and Trazadone for insomnia, but neither agitation nor insomnia was listed as a diagnosis in the EHR. Another resident was prescribed Lorazepam for agitation/anxiety, but anxiety was not documented as a diagnosis. Similarly, a third resident was prescribed Trazadone for insomnia without insomnia being listed as a diagnosis in the EHR. During an interview, the Director of Nursing confirmed that these medications were being administered for the indicated uses as per the physician's orders, despite the lack of corresponding diagnoses in the residents' records. The absence of documented indications for these medications constitutes a failure to ensure that drug regimens are free from unnecessary drugs, as required by regulation.