| 68 |
MERRY WOOD LODGE |
15019 |
P O BOX 130 |
ELMORE |
AL |
36025 |
2020-03-03 |
758 |
D |
1 |
1 |
LZCS11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, and review of the facility's policy titled [MEDICAL CONDITION] Medication Use, the facility failed to ensure Resident Identifier (RI) #24 was not given [MEDICATION NAME], an antipsychotic medication, without a [DIAGNOSES REDACTED]. This affected RI #24, one of six sampled residents reviewed for unnecessary medications. Findings include: Review of the policy titled 3.8 [MEDICAL CONDITION] Medication Use, revised 11/28/2016, revealed the following: POLICY This Policy 3.8 sets forth procedures relating to [MEDICAL CONDITION] medication use. DEFINITION A [MEDICAL CONDITION] drug is any medication that affects brain activities associated with mental processes and behavior, PROCEDURE . 3. [MEDICAL CONDITION] medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. . 8. Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause. RI #24 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of hospital records indicated RI #24 was transferred to the hospital on [DATE] due to complaints of chest pain, where he/she remained overnight until readmitted to the facility on [DATE]. Review of RI #24's current physician orders [REDACTED]. However, review of RI #24's order history, revealed RI #24 had not received [MEDICATION NAME] since the order was discontinued on 11/02/18. Further, review of RI #24's current comprehensive care plans revealed no care plan addressing any behaviors. RI #24's January and February 2020 Medication Administration Record [REDACTED]. A telephone interview was completed on 3/2/20 at 3:37 p.m. with Employee Identifier (EI) # 7, Nurse Practitioner. EI # 7 was asked if she was aware RI #24 was readmitted to the facility on [DATE] with [MEDICATION NAME]. EI # 8 stated she was not aware and that EI # 8, the Medical Director, would be the one to sign off on it. An interview was completed on 3/3/20 at 2:48 p.m. with EI # 5, Licensed Practical Nurse (LPN), the nurse that processed RI #24's readmission on [DATE]. When asked how familiar she was with RI #24, EI # 5 said she was very familiar because RI #24 was her resident from the time of his/her original admission. EI # 5 said she was the nurse at the time RI #24 was readmitted on [DATE] and she had completed the admission. When asked what her responsibility was as the admitting nurse for reviewing the resident's medications. EI # 5 said she was responsible for making sure the orders were transcribed into the computer. When asked what the rationale for use of the [MEDICATION NAME] was when RI #24 returned from the hospital, EI # 5 said she had no idea, nor did she know if RI #24 was receiving the [MEDICATION NAME] before going to the hospital. EI # 5 further stated [MEDICATION NAME] was an antipsychotic medication. When asked why she had not questioned the order for the [MEDICATION NAME], EI # 5 said she did not know; she just assumed RI #24 was taking it before going out to the hospital. EI # 5 said she should have compared the medication orders RI #24 was taking prior to going to the hospital with the ones listed after RI #24's return, but she had not done that. When asked why it was important to have a rationale for the use of an antipsychotic medication, EI # 5 said the resident should not be on the medication if he/she does not need it. EI # 5 was then asked if RI #24 had any sort of behaviors prior to going out to the hospital, EI # 5 said RI #24 would sometimes have some anxiety, but they would get RI #24 and his/her roommate together and RI #24 would calm down. When asked if RI #24 displayed any behaviors after returning from the hospital, EI # 5 said he/she would complain of chest pain. When asked about the facility's policy regarding the use of antipsychotic medications, EI # 5 said anyone with orders for an antipsychotic should have a behavior sheet on their Medication Administration Record [REDACTED]. During a follow-up interview with EI # 5 on 3/03/20 at 5:24 p.m., EI # 5 stated she faxed the Medical Director, EI # 7, a copy of RI #24's admission orders [REDACTED]. EI # 5 said she had called the Medical Director and discussed pain medication orders but she did not recall asking about the [MEDICATION NAME]; she had just assumed RI #24 had been receiving it before going to the hospital. On 3/03/20 at 3:18 p.m., a consultant Pharmacist (Pharmacist #1) was asked to explain the Use of [MEDICAL CONDITION] Medications policy and the reference to a clinically indicated use and rationale. Pharmacist #1 stated there were a number of psychiatric disorders, as well as behaviors with intention for harm, that would warrant the use of antipsychotic medication. Pharmacist #1 stated he had not reviewed the policy in some time and did not realize it was so vague. When asked about [MEDICATION NAME] and whether Dementia or Alzheimer's would be an appropriate [DIAGNOSES REDACTED].#1 said no, unless there were documented behaviors or other diagnoses. Pharmacist #1 stated he filled medication orders, but Pharmacist #2 was in the facility each month to review medication orders. Pharmacist #2 was interviewed on 3/03/20 at 3:35 p.m. Pharmacist #2 stated RI #24 had been prescribed [MEDICATION NAME] once daily for Alzheimer's. When asked what types of [DIAGNOSES REDACTED].#2 said dementia with associated behaviors. He further stated Alzheimer's was not the best [DIAGNOSES REDACTED].#24's [MEDICATION NAME]. After reviewing the information he had available on RI #24, Pharmacist #2 said he had notes indicating he had recommended a dose reduction on RI #24's [MEDICATION NAME] on 7/2/18 and it had been completely discontinued as of his note on 12/4/18. Pharmacist #2 also indicated another pharmacist (Pharmacist #3) made a note on 1/28/20 that indicated RI #24 was receiving [MEDICATION NAME] 25 mg daily for Dementia. When asked what was an adequate rationale for use of an antipsychotic, Pharmacist #2 said [MEDICAL CONDITION]'s, [MEDICAL CONDITION], or Dementia with behaviors; He further stated dementia without behaviors would not be a reason to warrant use of [MEDICATION NAME]. Pharmacist #2 also said he had met with the facility in February to discuss psychoactive medications, but he was not sure if RI #24's [MEDICATION NAME] had been discussed. He indicated EI # 9, the Director of Nursing (DON), would have the notes from that meeting. Pharmacist #3, that completed the admission medication review, was interviewed on 3/03/20 at 4:28 p.m. When asked what types of [DIAGNOSES REDACTED].#3 stated any psychiatric [DIAGNOSES REDACTED]. When questioned whether RI #24 should have received [MEDICATION NAME] after coming back from the hospital (after it had been discontinued since 2018), Pharmacist #3 said if there was no indication of harmful behaviors, she would hope the facility would consider getting the resident off of the medication. Pharmacist #3 further stated there have to be behaviors and dose reductions when residents are on antipsychotic medications. On 3/3/20 at 4:15 p.m., EI # 9, the DON, was asked about the February meeting referenced by Pharmacist #2, in which psychoactive medications were discussed, and whether RI #24's [MEDICATION NAME] had been addressed. EI # 9 stated they had discontinued another one of RI #24's medications, but had continued with the [MEDICATION NAME]. When asked what the [DIAGNOSES REDACTED].#24's [MEDICATION NAME], EI # 9 said Alzheimer's and [MEDICAL CONDITION]. When asked if those [DIAGNOSES REDACTED].# 9 said she did not know that those [DIAGNOSES REDACTED]. When questioned why RI #24 required the [MEDICATION NAME] after it had been discontinued for over a year, EI # 9 stated she would need to review the information in RI #24's chart to discuss the concern any further. On 3/3/20 at 4:39 p.m., EI # 9 returned and stated she had reviewed the information in RI #24's chart. When asked what information she had that justified the use of [MEDICATION NAME] for RI #24, EI # 9 said RI #24 had come back from the hospital with orders for it. EI # 9 went on to say that she did see notes that RI #24 had exhibited a few behaviors after returning from the hospital. When asked if the [MEDICATION NAME] was being used to address any specific target behaviors, EI # 9 said they had not attached any specific behaviors to the order for [MEDICATION NAME]. When asked where RI #24's behavior monitoring tools could be located, EI # 9 said they were captured in the nurses' notes. EI # 9 said in her review of RI #24's medical record, she found two instances of behaviors since RI #24's readmission on [DATE]: on [DATE] exit seeking was noted and there was another episode of the resident undressing. When asked if there had been any repetitive behaviors noted, EI # 9 said those were the only two instances she saw since [DATE]. When asked if that was enough to justify the use of the [MEDICATION NAME] for RI #24, EI # 9 said she could not just discontinue the medication. EI # 9 went on to say she did not know if anyone had specifically asked the Nurse Practitioner or Medical Director why RI #24 was back on the [MEDICATION NAME]. EI # 9 said the facility was responsible for ensuring they are in compliance with the requirements for antipsychotic usage. EI # 7, the Medical Director, was interviewed on 3/03/20 at 5:00 p.m. EI # 7 was asked if he recalled the MEDICATION ORDERS FOR [REDACTED]. EI # 7 said, yes, facility staff had called him and he was frustrated because RI #24 had been readmitted to the facility with an order for [REDACTED].# 7 said the order for the [MEDICATION NAME] never should have been entered/transcribed for RI #24 to continue. When asked what [DIAGNOSES REDACTED].# 7 said none in a dementia patient, only uncontrolled [MEDICAL CONDITION]. When asked how the facility had justified continuing the [MEDICATION NAME] for RI #24 after it had been discontinued for over a year, EI # 7 stated he does not use [MEDICATION NAME] for dementia, and the medication had been ordered for RI #24 in error. |
2020-09-01 |