Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. According to the facility's policy, psychotropic medications should only be used when nonpharmacological interventions are clinically contraindicated and must be supported by documented clinical rationale. For one resident with diagnoses including Alzheimer's disease, high blood pressure, and lumbar radiculopathy, the clinical record showed ongoing orders for Seroquel (Quetiapine) both as a scheduled and PRN medication for agitation and depression. The PRN order for Seroquel exceeded the 14-day limit set by policy, and there was no documentation of behaviors or clinical justification for continued use during the specified period. Additionally, a new PRN order for Seroquel was written at the request of the resident's family, again without documented evidence of behaviors or clinical rationale in the progress notes. Staff interviews confirmed that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication, as required by both facility policy and regulatory standards.