Patient Given Psychoactive Meds Without Documented Reason

Timberlawn Mental Health System was cited by the Centers for Medicare and Medicaid Services for failing to document the necessary information needed to monitor a patient’s condition. A patient was administered stat [immediate] psychoactive medication via injection, but there was no reason for administering the medication noted in the patient’s medical record. Furthermore, there was no documentation found indicating the patient was agitated/aggressive at the time the medication was administered. A nurse indicated that the patient’s behavior should have been documented in the progress notes and a reason for the injection should also have been documented.