Depakote Administered Without Documented Indication or Care Plan Inclusion
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary medication by administering Depakote without an associated diagnosis or adequate indication for its use. A resident admitted with diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood, Generalized Anxiety Disorder, and Insomnia had a quarterly MDS showing a BIMS score of 0, indicating severe cognitive impairment. The resident’s care plan, initiated for adverse medication effects and behavior monitoring, did not address that the resident was receiving Depakote. The medication order for Depakote Sprinkles 125 mg, to be given orally twice daily for mood stabilization, lacked an associated diagnosis. During interview, the DON acknowledged that the Depakote order should have had an associated diagnosis and that it did not, despite the facility’s Unnecessary Medications policy stating that each resident must remain free of unnecessary medications, including drugs used without adequate indications for their use. This deficient practice was identified for one resident reviewed for unnecessary medications and had the potential to affect all residents receiving prescription medications, as it demonstrated a failure to ensure that prescribed drugs had documented, adequate indications in accordance with facility policy.
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