Failure to Manage Psychotropic Medications and Documentation
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The clinical record review revealed that a resident with diagnoses of hypertension and bipolar disorder was prescribed clonazepam and lorazepam, both benzodiazepines, for anxiety and restlessness. These medications were continuously reordered without documented clinical rationale for their duplicative use, despite a pharmacy recommendation to consolidate the medications. The provider disagreed with the recommendation, citing perceived benefits over risks, but no documented review of the risks and benefits was found. Additionally, the facility did not adhere to the prescribed administration schedule for lorazepam. The Controlled Drug Record showed instances where lorazepam was administered less than six hours apart, contrary to the physician's orders. Furthermore, there were discrepancies between the Controlled Drug Record and the electronic Medication Administration Record (MAR), with numerous administrations not recorded in the MAR. The facility also administered lorazepam to the resident during a period when there was no active physician order for the medication. This occurred on multiple occasions, indicating a failure to ensure that medications were only administered with a valid physician order. The Director of Nursing confirmed that it was the facility's expectation for staff to follow prescribed time frames and document all medication administrations accurately.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R26. 2) The Facility reviewed R26, but resident has since discharged and no longer resides at the facility. 3) All current residents were reviewed for duplicate therapy and Physician documentation for Risk/Benefit and orders and signed Physician orders. 4) All current residents were reviewed for Medication Administration and Controlled drug record for correct administration times frames as prescribed and for missing documentation. Two: system changes and measures that will be taken: 1) All Licensed staff and Medical Director and Medical Providers will be in-serviced on documentation Psychotropic drug use, Duplicate Therapy, correct administration times frames as prescribed and for missing documentation. 2) Documentation will be monitored at Daily Clinical meetings for accuracy. 3) Pharmacy Consultant to review for accuracy and discrepancies. 4) Medical Director and his staff will be in-serviced on documentation for Risk/Benefits of use. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with Psychotropic drug use, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Penalty
A resident was administered PRN Ativan on three occasions, but documentation showed that non-pharmacological interventions were only attempted before two of those administrations. An LPN confirmed that there was no record of any intervention being tried prior to one of the doses, resulting in a deficiency related to the use of psychotropic medications.
A resident with dementia and behavioral disturbances received a PRN order for Lorazepam that was not limited to 14 days and lacked a documented rationale for continuation beyond this period. The medication was administered without evidence that non-pharmacological interventions were attempted first, and required documentation was missing.
The facility did not reassess a PRN psychotropic medication for a resident with severe cognitive impairment, allowing continued use without physician review, and also failed to complete an AIMS assessment for another resident receiving antipsychotic medication. Staff were unaware of the requirements for medication reassessment and AIMS completion.
Two residents received routine Seroquel administration without proper documentation of targeted behaviors, monitoring for adverse effects, or rationale for continued use. In both cases, there was no evidence of attempted gradual dose reduction (GDR) or clinical justification for not attempting GDR, and staff interviews confirmed these documentation gaps.
A resident admitted for hospice care with dementia and Parkinson's disease was prescribed lorazepam and quetiapine for anxiety and psychosis, but staff did not initiate monitoring for targeted behaviors or medication side effects until two days after starting the medications. Nursing staff and leadership confirmed that monitoring should have begun with the initiation of psychotropic medications, as required by facility policy.
A resident with moderate cognitive impairment was prescribed psychotropic medications, but the facility failed to complete and document required Gradual Dose Reductions (GDRs) as per regulatory standards. Only one GDR attempt was made for each medication over extended periods, and there was no supporting documentation for GDRs or contraindications. Staff were unclear on GDR requirements, and facility policy lacked specific time frames for GDR attempts.
Failure to Document Non-Pharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions (NPI) were provided or attempted prior to administering a psychotropic medication for one resident. Specifically, a resident was prescribed Ativan (Lorazepam) on an as-needed basis and received doses on three separate occasions. Documentation confirmed that NPIs were attempted before administration on two of those dates, but there was no documentation of any NPI being attempted prior to the administration on the third date. During interviews, an LPN explained that the facility's process is to attempt NPIs before administering psychotropic medications and that such attempts should be documented either in the electronic Medication Administration Record (eMAR) or in a progress note. Upon review of the resident's records, the LPN was unable to find any documentation indicating that an NPI was attempted before the administration of Ativan on the date in question, confirming the deficiency.
Failure to Limit and Document PRN Psychotropic Medication Orders
Penalty
Summary
Facility staff failed to ensure compliance with regulations regarding the use of as needed (PRN) psychotropic medications for a resident with dementia and behavioral disturbances. A physician order for Lorazepam, to be administered prior to blood draws, was written as a PRN order without a 14-day limitation or a specified duration and discontinuation date. The medical record did not contain documentation from the physician providing a rationale for continuing the PRN order beyond 14 days, as required by regulation. Additionally, review of the medication administration record showed that Lorazepam was administered to the resident, but there was no documentation indicating that non-pharmacological interventions were attempted prior to giving the medication. These findings were confirmed during interviews with the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of appropriate documentation and understanding of the requirements for PRN psychotropic medication orders.
Failure to Reassess PRN Psychotropic Medication and Complete AIMS Assessment
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary medications by not reassessing a PRN psychotropic medication as required. Specifically, a resident with severe cognitive impairment and diagnoses including depression and Alzheimer's Disease had a PRN order for trazodone to address restlessness and agitation. The order, initiated at admission, was not reassessed by the physician after the initial 14 days or at any subsequent time, despite ongoing use over several months. There was also no evidence that the resident was seen by behavioral health services for medication management. Facility staff, including the nurse and Director of Nursing, were unaware that the medication had not been re-evaluated as required by policy. Additionally, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for another resident who was receiving antipsychotic medication. This resident, admitted with diagnoses including suicidal ideations, depression, aphasia, and chorea, had a physician's order for daily risperidone. Review of the medical record showed no documentation that an AIMS assessment was completed, as required for residents on antipsychotic medications. Staff interviews revealed a lack of awareness and training regarding the completion and timing of AIMS assessments.
Failure to Monitor and Document Antipsychotic Use and GDR for Two Residents
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by policy and regulation. For one resident with Alzheimer's disease, dementia with agitation, major depressive disorder, and anxiety, Seroquel was administered routinely without identifying or monitoring resident-specific target behaviors or signs and symptoms of potential adverse consequences. Physician's orders for Seroquel did not specify targeted behaviors or monitoring parameters, and the medical record lacked documentation of monitoring for efficacy or adverse effects. For another resident with Alzheimer's disease, depression, and anxiety, Seroquel was also administered on a routine basis. The medical record did not contain a documented rationale for the use of Seroquel, nor was there evidence that a gradual dose reduction (GDR) was attempted or that a clinical contraindication to GDR was documented by the prescriber. Although a consultant psychiatric nurse practitioner recommended against GDR due to potential psychiatric destabilization, this recommendation was not reviewed or documented by the attending physician or nurse practitioner in the resident's record. Interviews with facility staff, including the Director of Nursing and Social Worker, confirmed that there was no documentation of resident-specific targeted behaviors, monitoring for adverse consequences, or rationale for continued use of Seroquel. The Director of Nursing acknowledged that these elements should have been documented but were not completed for the residents in question.
Failure to Monitor Behaviors and Side Effects for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring of a resident who was admitted under general in-patient hospice care with diagnoses including dementia, Parkinson's disease, and uncontrolled behaviors posing a danger to self and others. Upon admission, the resident was prescribed psychotropic medications, specifically lorazepam for anxiety, restlessness, agitation, and shortness of breath, and quetiapine fumarate for psychosis and unprovoked physical behavior. However, there was no documented evidence that monitoring for targeted behaviors such as anxiety and psychosis, or for side effects related to the use of these psychotropic medications, was initiated until two days after admission. Interviews with nursing staff and facility leadership confirmed that monitoring for behaviors and side effects should have been conducted from the time the medications were started. The facility's own policy required staff to monitor for adverse side effects associated with psychotropic medication use. The lack of timely monitoring was acknowledged by the RN, ADON, LVN, and DON, all of whom stated that such monitoring was expected and should have been implemented as soon as the medications were ordered.
Failure to Complete and Document Required Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a Gradual Dose Reduction (GDR) was completed for one resident reviewed for unnecessary medications. The resident, who was moderately cognitively impaired, was prescribed Sertraline for depression and Zyprexa for dementia with psychotic disturbance. Documentation showed only one GDR attempt for Sertraline in over two years and only one GDR attempt for Zyprexa in the previous thirteen months. There was no supporting documentation in the electronic health record (EHR) for a GDR on the date indicated in the Minimum Data Set (MDS), nor was there documentation from the pharmacy or provider requesting a GDR or supporting contraindications for GDR. Staff interviews revealed confusion regarding the requirements for GDRs, with staff referencing facility policy and pharmacy guidelines but unable to provide documentation supporting their practices. The facility's policy did not specify time frame requirements for GDR attempts, and no further documentation was provided to support that appropriate GDRs or contraindications had been addressed for the resident's psychotropic medications.
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