Failure to Monitor and Document Psychotropic Medication Use and Stop Dates
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications and did not follow established protocols for medication monitoring and documentation. For one resident with a history of dementia, psychotic disturbance, and schizoaffective disorder, an antipsychotic medication (aripiprazole) was administered without documented evidence of behaviors or symptoms justifying its continued use. Multiple staff interviews confirmed the absence of hallucinations, delusions, or paranoia, and the resident herself denied current symptoms. Despite this, the medication remained active, and the interdisciplinary team had not documented a recent evaluation supporting its necessity. Another resident with Alzheimer's disease and agitation, who was on hospice care, had an active PRN order for lorazepam (an antianxiety medication) without a required stop date. The DON was unaware of the need for stop dates on hospice-prescribed medications. Additionally, a third resident with PTSD, major depressive disorder, and ADHD had two PRN orders for Adderall (a CNS stimulant) without end dates, and the medication had not been administered since being ordered. The DON did not recognize Adderall as a psychotropic medication and believed that unused orders would be discontinued after 30 days, but the orders remained active. Review of facility policy indicated that psychotropic medications should not be used unless clinically indicated and that PRN orders for such medications must have a documented rationale and duration, especially if extended beyond 14 days. The facility's failure to ensure adequate monitoring, documentation, and adherence to stop-date requirements for psychotropic and CNS stimulant medications resulted in deficiencies for three residents reviewed.