Failure to Ensure Appropriate CMS-Approved Indication for Antipsychotic Therapy
Penalty
Summary
Surveyors identified a deficiency in the facility’s drug regimen review process related to the use of an antipsychotic medication for a resident with dementia. The resident’s EMR listed diagnoses of Alzheimer’s disease, cerebral infarction, insomnia, and major depressive disorder, with a BIMS score indicating severe cognitive impairment. The MDS showed the resident was independent in activities of daily living and did not exhibit behaviors during the assessment period, though it documented antipsychotic use. The CAA noted antipsychotic use and risk for adverse effects from Seroquel. The care plan, initiated earlier, described behaviors of resisting care and yelling out related to depression, anxiety, and dementia, and stated that Quetiapine (Seroquel) was used for these behaviors, but it lacked a clear psychiatric indication for the medication. The EMR contained a renewed order for Quetiapine 12.5 mg daily with an indication of unspecified dementia with psychotic disturbances, and there was no behavioral monitoring documented related to the antipsychotic use. Review of the consultant pharmacist’s monthly recommendations from May through February showed that the pharmacist recommended a gradual dose reduction of Quetiapine to the lowest effective dose, which the medical provider declined, citing risk of decompensation. The pharmacist’s recommendations did not address the use of the antipsychotic with the indication of dementia, and the facility could not provide documentation supporting a CMS-approved indication for the continued use of Quetiapine despite a request for such rationale. Observations showed the resident calm and engaged in group activity without behaviors. Interviews revealed that the consultant pharmacist stated the resident was admitted on the antipsychotic and that the representative refused changes or discontinuation, and that the medication was believed to be needed for dementia-related hallucinations and delusions. A nurse and an administrative nurse both stated that antipsychotics were not indicated for dementia alone and required a psychiatric diagnosis, and that the resident had been admitted with the medication and dementia diagnosis. This sequence of actions and inactions demonstrated a failure to ensure the consultant pharmacist addressed the lack of an appropriate CMS indication for the antipsychotic during the monthly drug regimen review, contrary to the facility’s drug regimen review policy.
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