Long-Term Care Survey Alert

Learn what every facility that uses anticonvulsant drugs for behavior management should know.

Don't be fooled: The recently released draft survey interpretive guidelines for unnecessary drugs aren't as much a case of "out with the old, in with the new" as you might think.

"The draft guidelines don't change the regulations," emphasizes Tom Clark, RPh, MHS, a member of the expert panel that developed the new guidelines.

Take for example, verbiage in the draft guidelines that cites use of two or more antipsychotic agents at the same time as a potential example of an unnecessary drug (without adequate indication). That language was included in the recently deleted Section N of the State Operations Manual, says Clark. "So surveyors actually have no guidance to that effect" at this point (given that the new guidance is in draft form).

Even so, under the regulations, surveyors could still cite a facility if they believe use of two antipsychotic drugs was not in a resident's best interest clinically, Clark notes.

New draft language also recognizes that facilities are using anticonvulsants as psychotherapeutic medications. Facilities prescribing these medications for behavior management or as mood stabilizers must monitor them for therapeutic effectiveness and adverse outcomes, the draft guidelines mandate.

And while the guidelines may be in draft form, existing regs and solid clinical practice require an accurate diagnosis and indication for use of a medication. You would, however, code an anticonvulsant in MDS Section 0 based on its pharmaceutical classification rather than its intended therapeutic action.

But make sure everyone on the interdisciplinary team knows why the physician ordered the medication. "Without a diagnosis documented in the medical record, nurses may assume the medication is for seizures," says Sandra Kay Webb, RN, BS, with Survey Future Enterprises in Grove City, OH. 

"The care plan cannot be accurate without the appropriate behavioral assessment, diagnosis and monitoring of the drug for a therapeutic effect," adds Webb.

"Monitoring residents taking antipsychotics or anticonvulsant drugs for behavioral issues is twofold," says Clark. "The facility must assess the drug's effectiveness in treating the targeted behavioral issues - and any drug-related adverse effects." And the side effect profiles for antipsychotics and anticonvulsant drugs are very different, he adds.

Watch out: Physicians may reason that surveyors are less likely to view an anticonvulsant used to treat behaviors as a restraint, but these drugs can actually be quite sedating, cautions Adam Rosenblatt, MD, a geropsychiatrist with Johns Hopkins Medical Center.