Failure to Attempt Non-Pharmacological Interventions Before Antipsychotic Use
Penalty
Summary
The facility failed to ensure that unnecessary antipsychotic medications were not administered to residents without first attempting non-pharmacological interventions. For two sampled residents, both with significant neurological and psychiatric diagnoses, there was no documented evidence that non-drug approaches were tried prior to the administration of quetiapine, an antipsychotic medication. Review of clinical documentation, medication orders, and electronic medication administration records confirmed that both residents received quetiapine nightly over several months without any record of alternative interventions being attempted beforehand. Interviews with the facility's DON confirmed the absence of documentation for non-pharmacological interventions prior to administering the antipsychotic medication to both residents. The facility's own policy requires that non-pharmacological interventions be attempted before resorting to antipsychotic medications, except in cases where behavioral symptoms are not sufficiently relieved by such interventions. The lack of adherence to this policy was verified through record review and staff interview.