Failure to Prevent Unnecessary Use of Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cerebral infarction, glaucoma, anxiety disorder, and vascular dementia was administered an antipsychotic medication (Haldol) without proper documentation or justification. The resident, who had intact cognition and required assistance with transfers, had no routine psychoactive medication orders. After returning from the hospital, the resident exhibited agitation and combative behavior, leading to a one-time order for Haldol and Ativan if needed for agitation and aggression. However, the medications were not administered at that time, and the resident later rested calmly. Over 24 hours later, an LPN administered Haldol to the resident after the resident attempted to hit the nurse during a dressing change. There was no documentation in the progress notes to indicate the reason for administering the medication at that time, and behavior tracking did not show any documented behaviors warranting its use. Facility policy required that antipsychotic medications only be used for specific conditions and after other causes of behavioral symptoms had been addressed. The Acting DON confirmed there was no evidence of imminent danger to self or others to justify the use of Haldol, and the only incident noted was the resident pulling a fire alarm earlier, with no further documentation.