Failure to Implement Non-Pharmacological Interventions Prior to Antipsychotic Use
Penalty
Summary
A deficiency occurred when the facility failed to prevent the use of unnecessary psychotropic medications for a resident with severe cognitive impairment and multiple medical diagnoses, including cancer, anxiety disorder, and depression. The facility administered antipsychotic medication (haloperidol) to the resident without first implementing or documenting non-pharmacological interventions to address the resident's behaviors, as required by facility policy. The medical record lacked evidence of behavioral assessments, documentation of specific behaviors or symptoms, and the resident's response to non-pharmacological interventions prior to the administration of antipsychotic medication. The resident was bedbound, receiving hospice services, and had a history of restlessness, agitation, and calling out. Staff interviews revealed that the resident was not regularly checked on, did not use a call light, and was not on frequent checks. Although the care plan included interventions such as sensory activities, companionship, and music, these were not consistently implemented or documented. Staff primarily addressed restlessness by offering snacks, water, and repositioning, but there was no evidence that these or other non-pharmacological strategies were attempted or evaluated before resorting to medication. The facility's records showed that the resident received both lorazepam and haloperidol for agitation and restlessness, with medication orders being changed due to perceived ineffectiveness. However, there was no documentation of the required assessments or monitoring for side effects, and the care plan did not include a specific plan for antipsychotic medication use. Staff interviews confirmed that non-pharmacological interventions were not consistently provided or documented, and the facility did not obtain a risks versus benefits statement regarding getting the resident out of bed, despite conflicting information about the resident's preferences and family wishes.