Failure to Document Nonpharmacological Interventions Before Administering Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications for two residents. Facility policy required that psychotropic medications only be used when nonpharmacological interventions were clinically contraindicated, and that such medications should not be used for staff convenience or as a chemical restraint. For one resident with severe cognitive impairment, dementia, and anxiety, clinical records showed repeated administration of Alprazolam as needed for anxiety, but there was no documented evidence that nonpharmacological interventions were attempted prior to each administration. This was confirmed by the Director of Nursing, who acknowledged the lack of documentation for attempted nonpharmacological approaches before giving the medication. Similarly, another resident with cognitive impairment, dementia, depression, and anxiety received Lorazepam as needed for anxiety on multiple occasions. Review of the clinical record revealed no documentation that nonpharmacological interventions were attempted before administering the medication. The Director of Nursing also confirmed the absence of such documentation for this resident. These findings indicate that the facility did not follow its own policy or regulatory requirements regarding the use of psychotropic medications and the documentation of nonpharmacological interventions.