Failure to Accurately Document Discontinuation of Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the discontinuation of an antipsychotic medication and the rationale for that change in a resident’s clinical record. The resident was admitted from the hospital with an order for olanzapine 2.5 mg daily and had moderate cognitive impairment with no documented behavioral symptoms during the MDS assessment period. Facility physician orders showed olanzapine was started with an indefinite end date, and the MAR reflected administration for several days, with the medication discontinued on November 11, 2025, at 11:41 a.m. A behavioral monitoring order related to olanzapine, initiated the day before, remained active through the resident’s discharge, and no behavioral symptoms were documented during that time. On the same day olanzapine was discontinued, a psychiatry progress note by a PA documented that this was the initial psychiatric visit and stated that no medication changes were recommended, without noting the discontinuation of olanzapine and directing staff to refer to the MAR for non-pharmacologic interventions. A telephone discontinue order for olanzapine was entered by an LPN as a telephone order from the same PA, and the MAR confirmed no further doses were given after that date. Subsequent nurse practitioner notes on two later dates documented that the resident would continue olanzapine and benztropine for psychosis, despite the medication having been discontinued and not provided, and the resident was ultimately discharged without a prescription for olanzapine. Interviews with nursing and pharmacy staff, as well as the PA, confirmed that the discontinuation was not documented in the progress note and that behavioral monitoring and alert charting were not updated, contrary to facility policies requiring accurate documentation of physician-ordered services and nursing documentation of treatment and order changes.
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