Failure to Ensure Drug Regimen Free from Unnecessary Antipsychotic Medication
Penalty
Summary
A deficiency was identified when a resident with diagnoses of cerebral ischemia, dementia without behavioral disturbance, and psychosis was prescribed Haldol 2 mg every six hours without a clearly documented indication and without consideration of psychiatric recommendations to decrease the dosage. The resident's medical records showed that Haldol was initially ordered as needed for psychosis following a hospital discharge, but the order was later changed to a scheduled dose every six hours after the resident exhibited behavioral disturbances. The facility's policy required that psychotropic medications only be prescribed when necessary to treat a specific, diagnosed condition based on a comprehensive review, but documentation did not show that this process was followed. Additionally, the pharmacist flagged the Haldol order as off-label and recommended a risk-benefit assessment, but there was no evidence this was completed. Further, a psychiatry consult recommended reducing the Haldol dosage, but there was no documentation that the physician reviewed or responded to this recommendation. The care plan did not include interventions to address the risks and side effects associated with Haldol use. Observations during the survey period found the resident confused, incoherent, and inappropriately dressed, as well as sleeping in a wheelchair. Interviews with the psychiatrist and medical director revealed a lack of communication and follow-through regarding medication changes, with the medical director unaware of the psychiatrist's recommendation to reduce the Haldol dosage.