Failure to Ensure Proper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications. Upon review, it was found that a resident was admitted with multiple psychotropic medications, including duloxetine, mirtazapine, sertraline, and quetiapine. The clinical record did not contain documentation of education provided to the resident or their representative regarding the risks and benefits of these medications, nor was there evidence of informed consent for their administration. Additionally, there was no documentation of identified target behaviors, behavior monitoring, or side effect monitoring related to the use of the antipsychotic medication. The facility's policies require an interdisciplinary evaluation before initiating, modifying, or discontinuing psychotropic medications, as well as the use of non-pharmacological interventions and obtaining informed consent. Despite these requirements, the resident's care plan did not identify target behaviors, and there was no evidence that non-pharmacological alternatives were considered or discussed. The facility also failed to document any rationale for duplicate therapy or to ensure that medications prescribed by specialists were clinically indicated and properly documented. A consultant pharmacist issued a recommendation to the resident's physician to review the use of antipsychotic medication due to black box warnings and lack of a supporting diagnosis. However, there was no timely physician response or documentation addressing this recommendation. The resident's practitioner did not consult psychiatric services until several weeks after the pharmacist's recommendation, and there was no documentation of actions taken during multiple practitioner visits. Facility leadership confirmed that required monitoring and documentation were not completed at the time of admission.