Failure to Document Indications for Medication Use
Penalty
Summary
The facility failed to document the indications for use for multiple medications administered to two residents, as required by facility policy. Policy review showed that all medication orders must include a diagnosis or indication for use, and that psychotropic medications specifically require documentation of the condition being treated. For one resident with multiple diagnoses including hemiplegia, diabetes, depression, dementia, bipolar disorder, hypertension, and anxiety, medical record review revealed that several medications—such as aspirin, insulin, risperidone, and MiraLAX—were ordered without any documented indication for use. The DON confirmed that these medications lacked the required documentation specifying the reason for administration. Similarly, another resident with diagnoses including COPD, bipolar disorder, delusional disorders, depression, anxiety, and neuropathy was found to have several medications ordered without an indication for use. These included Ativan, Remeron, clonidine, trazodone, Lipitor, and promethazine. The DON also confirmed that these medications did not have a documented diagnosis or indication for use in the medical record, in violation of facility policy.