Failure to Document Indications and Nonpharmacological Interventions Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic and antipsychotic medications were only used when clinically indicated and after nonpharmacological interventions had been attempted or deemed clinically contraindicated. For three residents reviewed, there was a lack of documented behaviors to warrant the use of these medications, and no evidence that nonpharmacological interventions were tried prior to administration. Facility policy requires that psychotropic medications be used only for documented medical symptoms and not for staff convenience or discipline, and that behavioral interventions should be exhausted before resorting to such medications. One resident with severe cognitive impairment and a history of dementia, anxiety, insomnia, and repeated falls received multiple psychotropic medications, including Hydroxyzine and Haloperidol, without documentation of the specific behaviors leading to administration or any nonpharmacological interventions attempted beforehand. The care plan for this resident did not include nonpharmacological strategies, and staff confirmed that education interventions would not be effective due to the resident's cognitive status. Another resident with Alzheimer's disease and depression was receiving Donepezil for dementia, with care plans noting behavioral symptoms such as wandering and involvement in altercations, but there was no behavior monitoring documented as required. A third resident with bipolar disorder, anxiety disorder, and paranoid schizophrenia was prescribed multiple antipsychotic and psychotropic medications, with physician orders specifying that staff should monitor and document specific target behaviors. However, the medical record lacked any behavior monitoring documentation as ordered. Facility leadership confirmed the absence of required behavior monitoring for these residents, indicating a systemic failure to document both the need for psychotropic medication use and the exhaustion of nonpharmacological interventions prior to administration.