Failure To Monitor Need For Antipsychotic Drugs

By: Donna Russo, Esq.
In Golden Living Center-Colonial Manor v. Centers for Medicare and Medicaid Services, Docket No. C-11-398 (decided 2/22/12), the Appeals Board of the Department of Heath and Human Services affirmed penalties against the nursing home for failure to monitor for the need, reduction or discontinuation of the administration of antipsychotic drug Haldol to a resident.

The power to penalize nursing homes arises out of the Social Security Act which sets forth the requirements for a nursing homes’ participation in the Medicare program. The Medicare program authorizes the Secretary of Health and Human Services to promulgate regulations which are found at 42 C.F.R. Part 483. Nursing homes must be in substantial compliance with these regulations to participate in Medicare programs. Substantial compliance means that the deficiencies pose no greater risk to resident health and safety than “the potential for causing minimal harm”.

Special rules apply to the use of antipsychotic drugs. Under 42 C.F.R. 483.25(1)(2), the facility must insure that a resident who has not used antipsychotic drugs is not given these drugs unless necessary “to treat a specific condition as diagnosed and documented in the clinical record.” Unless contraindicated, the facility must gradually reduce the doses and implement behavioral interventions to discontinue the antipsychotics.

In this case, a nursing home resident who suffered from congestive heart failure, chronic obstructive pulmonary disease, hypertension, diabetes, obesity sleep apnea and osteoarthritis, was admitted to the hospital for infections. Prior to the hospital admission, this resident was not prescribed antipsychotic drugs. While at the hospital, the resident suffered bouts of delirium and agitation. The hospital prescribed Haldol .5 mg.

The resident was in the hospital for over a week. Upon discharge from the hospital to the nursing home, the nursing home continued the resident on Haldol without an care plan for the use of antipsychiotics. The resident was kept of Haldol for 24 days until discontinued by a psychologist.

The nursing home disputes the contention hat the resident was not evaluated upon readmission to the nursing home. However, there was no reference to an evaluation, assessment, order or referral in the chart. There was no documentation to support evaluation upon return from the hospital nor a review for signs and symptoms of delirium which indicated the continued use of Haldol. There was no documentation to support proper monitoring for potential side effects and symptoms.

The Appeals Division found that the nursing home was not in substantial compliance with 42 C.F.R. 483.60 (a) and (b) which requires:

(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

(b) The facility must employ or obtain the service of a licensed pharmacist who–

(1) Provides consultation of all aspects of the provision of pharmacy services in the facility;
(2) Establishes a system of records or receipt and disposition of all controlled drugs in sufficient detail
to enable an accurate reconciliation; and
(3) Determines that drug records are in order and that an account of all controlled drugs is
maintained and periodically reconciled.