F0740

D

Failure to Address Repeated Refusal of Behavioral Health Medication

Indianapolis, Indiana Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident with bipolar disorder received necessary behavioral health services when she repeatedly refused a prescribed medication for insomnia without appropriate follow-up. The resident, who was not cognitively impaired and had diagnoses including bipolar disorder, morbid obesity, and diabetes, reported that she believed she had refused an insomnia medication and had been sent to the hospital because she did not care if she died. Physician orders showed trazodone 50 mg at bedtime was started and later discontinued, and the MAR documented multiple refusals of this medication across numerous dates. A behavioral health note recorded that the resident presented to the emergency department with passive suicidal ideations, several life stressors, increased emotionality, and reported inconsistencies with her antidepressant medication.

Despite these refusals and behavioral health concerns, the clinical record lacked documentation that the physician was notified of the ongoing refusals until the date trazodone was discontinued. A late-entry progress note indicated the resident’s refusal of trazodone had been discussed in a care plan meeting, but the Social Service Director stated he was not aware of the details of the refusals, and the Social Service Assistant reported she was unaware both of the trazodone prescription and the resident’s refusals. The Social Service Assistant indicated that medication refusals are normally discussed in clinical meetings, but this resident’s refusals had not been discussed to her knowledge. The facility’s charting and documentation policy required that all services performed and changes in condition be recorded to ensure consistency between family, physicians, and social services, but this was not followed in this case.