Documentation Power Tools                                                   25 years experience in long term care

Using the CMS form HCFA-805, Surveyors will evaluate drug therapy for indications/reasons, side effects, dose, evidence of unnecessary medications including Psychotropic medications, and correlation of the drug therapy with the resident's clinical condition. They will also evaluate the number of medications as outlined in the Quality Indicator: Use of 9 or more medications.

Consider the unique responses of the geriatric resident to medication. The elderly are more likely to experience drug toxicity, slower absorption, impaired distribution, slower metabolism of medications, and inefficient elimination.

Some general medication evaluation principles for geriatric residents are:
Minimize the number of medications used
Consider alternatives
Start low, go slow - increase doses gradually
Review medications on a regular basis

Psychotropic medications have the potential to cause side effects that can greatly impair the resident's quality of life, so the use of these medications should be monitored and documented carefully and thoroughly. Comprehensive monitoring and tracking includes making sure that:

• Supporting diagnosis for use of the medication is in the chart
• Attempt for reduction has been requested of the physician at least quarterly, and is documented in the chart
• MAR / Behavior flow sheet is filled out daily, and records behavior interventions
• Behavior and possible side effects of the medication are addressed in the long-term care plan Quarterly or AIMS assessment is done

The Psychotropic RAP Guidelines suggest reviewing conditions that affect drug metabolism/excretion (Impaired liver/renal function, acute condition, dehydration) and the Behavior/Mood status (Current behavior problem, Recent changes, Behavior management program, Psychiatric diagnoses)

Assessment of a resident for the use of Psychotropic medication should document well the nature of the problem and its response to non-drug interventions, and evaluate the risk for side effects in relation to resident's distress without the medication. The general rule for geriatric residents and medications is: "Start low, go slow", to minimize side effects. Encourage the physician to increase the dose slowly, and make sure each change and its effects are well documented. The goal is to reach a therapeutic dose without side effects.

• High fever
• Muscle rigidity
• Orthostatic Hypotension
• Sedation
• Dry mouth
• Balance problem, unsteady gait, risk for falls
• Restlessness
• Tremors, especially of hands, pill-rolling of hands
• Parkinsonism - muscle rigidity of limbs, neck, trunk
• Akinesia - marked decrease in spontaneous movement
• Dystonia - rigid, unnatural, uncomfortable posture of neck or trunk
• Akathesia - restlessness, inability to sit still
• Tardive Dyskinesia - persistent movements of the mouth, thrusting of tongue, movements of the lips, an/or peculiar and recurrent postures of limbs, trunk
• High fever and/or muscle rigidity are especially a concern because Psychotropics can potentially cause hyperthermia.

1. Unnecessary drugs--(1) General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
   1. In excessive dose (including duplicate drug therapy); or
   2. For excessive duration; or
   3. Without adequate monitoring; or
   4. Without adequate indications for its use; or
   5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
   6. Any combinations of the reasons above.
2. Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--
   1. Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and
   2. Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
   (m) Medication Errors. The facility must ensure that--
   1. It is free of medication error rates of five percent or greater; and
   2. Residents are free of any significant medication errors.

"Significant medication error" means one which causes the resident discomfort or jeopardizes his health and safety. "Medication error rate" is determined by calculating the percentage of errors. The equation for calculating a medication error rate is as follows:
Medication Error Rate = Number of Errors Observed divided by the Opportunities for Errors A medication error rate of 5% or greater indicates the facility may have systemic problems with its drug distribution system and a deficiency should be written.

The facility assures that residents who are undergoing antipsychotic drug therapy receive adequate monitoring for significant side effects of such therapy with emphasis on the following:
Tardive dyskinesia
Orthostatic hypotension
Cognitive/behavior impairment
Akathesia
Parkinsonism

Antidepressant Drugs: Consider drug therapy "unnecessary" only after determining that the facility's use of the drug is:
In excessive dose
For excessive duration
Without adequate monitoring
Without adequate indications of use
In the presence of adverse consequences which indicate the dose should be reduced or discontinued.

• Type of medication with its start date
• Supporting diagnosis for use of the medication is in the chart
• Attempt for reduction has been requested of the physician at least quarterly, and is documented in the chart
• MAR / Behavior flow sheet is filled out daily, and records behavior interventions

"Significant medication error" means one which causes the resident discomfort or jeopardizes his health and safety. "Medication error rate" is determined by calculating the percentage of errors. The equation for calculating a medication error rate is as follows:
Medication Error Rate = Number of Errors Observed divided by the Opportunities for Errors A medication error rate of 5% or greater indicates the facility may have systemic problems with its drug distribution system and a deficiency should be written.

The facility assures that residents who are undergoing antipsychotic drug therapy receive adequate monitoring for significant side effects of such therapy with emphasis on the following:
Tardive dyskinesia
Orthostatic hypotension
Cognitive/behavior impairment
Akathesia
Parkinsonism

Antidepressant Drugs:
Consider drug therapy "unnecessary" only after determining that the facility's use of the drug is:
In excessive dose
For excessive duration
Without adequate monitoring
Without adequate indications of use
In the presence of adverse consequences which indicate the dose should be reduced or discontinued.

• Type of medication with its start date
• Supporting diagnosis for use of the medication is in the chart
• Attempt for reduction has been requested of the physician at least quarterly, and is documented in the chart
• MAR / Behavior flow sheet is filled out daily, and records behavior interventions

More information on psychotropic medications can be found in the books:

 Psychosocial Care Plans for Long Term Care

Special Care Topics for Long Term Care, Vol. II

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