Failure to Prevent Use of Unnecessary Psychotropic Medications as Chemical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from chemical restraints, specifically regarding the administration of unnecessary psychotropic medications. Staff C, an RN, discovered a clear liquid in an unmarked medication cup in the medication cart, which Staff D, another RN, identified as lorazepam intended for a resident other than those prescribed. Staff D admitted to giving this controlled medication to two residents, not prescribed the medication, in response to their nighttime wandering and behaviors. Documentation and interviews confirmed that this practice occurred on several occasions. Resident 1, who had diagnoses of Alzheimer's disease and dementia with severe mood disturbance, exhibited unusual sleep patterns and difficulty getting out of bed following the suspected administration of lorazepam. Nursing notes indicated that Resident 1 was verbally aggressive and exit-seeking during the night, followed by an atypical period of extended sleep and lethargy the next day. Observation later showed the resident to be cognitively impaired but active and interactive, which contrasted with the documented behavior after the suspected medication administration. For Resident 3, records showed cognitive impairment and discharge from the facility, but there was no sleep chart or supporting evidence of side effects from the alleged administration of lorazepam. The facility's investigation found an opened bottle of lorazepam, prescribed for another resident, that had been tampered with and removed from use. The administrator acknowledged that the sleep and activity changes in Resident 1 were not typical and likely supported the occurrence of chemical restraint.