Psychotropic and Related Medications Used Without Corresponding Diagnoses
Penalty
Summary
Facility staff failed to ensure that psychotropic and related medications were prescribed and documented as medically necessary to treat specific, diagnosed conditions for multiple residents. One resident admitted with diagnoses including gastroenteritis, hypotension, chronic pain, constipation, paraplegia, and major depressive disorder had active orders for melatonin 3 mg at bedtime for insomnia and tetrabenazine 12.5 mg three times daily for tardive dyskinesia, despite having no documented diagnoses of insomnia or tardive dyskinesia in the clinical record. Another resident admitted with depression, insomnia, cerebral infarction, and hyperlipidemia had an order for hydroxyzine 50 mg twice daily for anxiety/agitation, but there was no documented diagnosis of anxiety in the record. A third resident admitted with respiratory failure, anxiety disorder, history of ischemic attack, dissociative identity disorder, bipolar disorder, and major depressive disorder had an order for Depakote 125 mg three times daily for dementia with behavioral disturbance, although there was no diagnosis of dementia documented in the record. During interview, the DON confirmed that these residents did not have the corresponding diagnoses (insomnia, tardive dyskinesia, anxiety, or dementia) for which the medications were ordered, and acknowledged that medications should be documented to treat specific conditions as diagnosed, which was not done in these cases.
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