Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. Clinical record review showed that a resident with diagnoses of dementia, anxiety, and high blood pressure was prescribed Ativan 0.5 mg every six hours as needed for a period of three months. The physician's order did not include a required 14-day stop date, nor was there any documented rationale for extending the medication beyond 14 days. The resident received Ativan on 27 occasions in one month and 22 occasions in the following month. Additionally, there was no documentation in the resident's progress notes indicating that non-pharmacological interventions were attempted prior to administering the Ativan. Staff interviews confirmed that facility policy requires the use of non-pharmacological interventions before administering psychotropic medications and mandates documentation of both the interventions and the behaviors. The Chief Nursing Officer acknowledged that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication.