Failure to Monitor and Review Psychotropic Medications Leading to Unnecessary Chemical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident receiving multiple psychotropic medications was free from unnecessary chemical restraints. The resident had diagnoses including unspecified dementia, difficulty walking, and Non-Hodgkin lymphoma, and was admitted from a general acute care hospital with recurrent falls and later documented as lacking capacity to make medical decisions. The resident’s MAR over a two‑month period showed scheduled Duloxetine for depression, Clonazepam for anxiety, Depakote for irritation and mood stabilization, Seroquel for schizophrenia with aggressive anger, and PRN Lorazepam for anxiety manifested by yelling and screaming, with the Lorazepam dose increased after a physician call related to inability to sleep and roaming. Psychiatric evaluations documented that the resident remained delusional, believing people were in her room, yet the quarterly IDT meeting and a later IDT admission review documented no medication review, contrary to the facility’s psychoactive medication management policy requiring at least quarterly review of response to psychoactive medications and consideration of continued use, dose reduction, or discontinuation. The MDS showed the resident had a severely impaired BIMS score and required substantial to maximal assistance with most ADLs, but there was no evidence that this functional and cognitive status was incorporated into a systematic review of the psychotropic regimen. The MDS coordinator confirmed that the required IDT psychoactive medication reviews were not conducted, including after multiple falls. Nursing staff interviews further demonstrated a lack of appropriate monitoring and use of alternatives related to the psychotropic medications. An LVN stated the resident was being monitored for crying, yelling, anger, and resisting care, and that monitoring was intended to support medication reduction, but also acknowledged that behaviors tied to each medication and side effects such as tardive dyskinesia, cognitive impairment, akathisia, and parkinsonism were not being monitored. An RN reported that Lorazepam was used when the resident was getting out of bed and crying, and that she could not stay with the resident due to other duties. The RN also stated there was no documentation of non‑pharmacological alternatives attempted before administering PRN Lorazepam, despite it being given repeatedly over two consecutive months, indicating the resident was subjected to psychotropic use without documented behavioral monitoring, side‑effect monitoring, or attempts at alternatives as required by facility policy.
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