Failure to Ensure Appropriate Indication and Notification for New Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary medications by not establishing and documenting appropriate indications for new psychotropic drugs. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur had no documented history of generalized anxiety disorder, depression, or other psychiatric conditions in the medical record. Review of progress notes over several days showed no signs or symptoms of anxiety and no documentation of referral to psychiatric services. During an admission psychiatric evaluation, the consulting psychiatrist documented the resident’s self-reported sadness, depression, poor sleep, anxiety, and restlessness, diagnosed generalized anxiety disorder, ordered BuSpar 10 mg orally twice daily for anxiety, and Trazodone 25 mg orally every evening while depression was still being ruled out and not listed as a confirmed diagnosis. The nursing documentation did not reflect the psychiatrist’s assessment or the new orders for BuSpar and Trazodone on the date they were made, and there was no documentation of notification of the resident’s responsible party regarding the initiation of BuSpar. The MAR showed the BuSpar order was entered the day after the psychiatric evaluation, and the resident received two doses before discontinuation. The responsible party later reported that the medications were started for an unknown reason, stated the resident had prior adverse reactions to psychotropic medications, and did not want medications that cross the blood-brain barrier. Interviews with the ADONs revealed conflicting accounts about whether and when the responsible party was notified of the new orders, with one ADON stating she did not notify the family by phone and that all communication was in person, and acknowledging that nothing was discussed regarding the rationale for Trazodone. The facility’s policy required immediate notification of the resident and authorized representative, consultation with the practitioner, and documentation in the medical record when there is a change in mental, physical, or psychosocial status, which was not consistently followed in this case.
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