Failure to Document Indications and Monitoring for Psychotropic Medications
Penalty
Summary
Surveyors found that the facility failed to ensure a resident’s psychotropic medication regimen was free from potentially unnecessary medications and lacked adequate indications for use. Facility policy dated 8/15/25 required that all residents receiving psychoactive medications have their behaviors, the effectiveness of pharmacological and non-pharmacological interventions, and the potential for gradual dose reduction monitored and documented. One resident, admitted on 3/27/2026 with diagnoses including paraplegia, depression, anxiety disorder, and bipolar disorder, had physician orders for multiple psychotropic medications: buspirone 10 mg (2 tablets three times daily), escitalopram 20 mg once daily, mirtazapine 15 mg at bedtime, and quetiapine 100 mg at bedtime plus quetiapine 25 mg once daily. The clinical record did not contain specific diagnoses linked to the use of each of these medications. Review of the resident’s clinical record also showed no documented non-pharmacological interventions, no documentation of the effectiveness of the prescribed psychotropic medications, and no evidence of monitoring for side effects or behaviors related to psychotropic use. During interviews, the RN Assessment Coordinator confirmed that the psychotropic medication orders lacked diagnoses for usage and that the record did not include documentation of interventions, medication effectiveness, or monitoring of side effects and behaviors. The Administrator and DON likewise confirmed that the facility failed to ensure the resident’s medication regimen was free from potentially unnecessary psychotropic medications without adequate indications for use, as required by state regulations and facility policy.
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