Failure to Monitor and Clarify Psychotropic Medication Use
Penalty
Summary
The facility failed to properly manage and monitor the use of psychotropic medication for a resident, identified as R88, who was prescribed divalproex sodium (Depakote) for agitation. The clinical record review revealed that there was no documentation indicating that the nursing staff clarified the order with the physician to ensure adequate indications for its use. Additionally, the nurse did not verify the order to clarify the duration, dosage, and intended use of Depakote, nor did they confirm whether it was to be administered as needed or on a standard schedule. Furthermore, there was a lack of documentation for Valproic acid blood levels, which are necessary to monitor the continued use of the medication. The psychiatrist's assessment noted that the resident had dementia with behavioral disturbances and was exhibiting agitation with aggressive behaviors. Despite this, the nursing staff failed to obtain an order for adequate monitoring of the drug and did not ensure that the medication was not used for an excessive duration. An interview with the director of nursing confirmed these deficiencies, highlighting the facility's failure to adhere to its policy on psychotropic drug use, which requires monitoring for adverse side effects, appropriate drug selection, and dosage.
Plan Of Correction
The facility has assessed resident R88 for the use of Depakote. The nurse has clarified the other for the Depakote with the physician to provide adequate indications for its use for resident R88. The facility will complete an audit for all residents on Depakote to verify that documentation and order substantiates the appropriate use of Depakote. The facility conducted a review of the current Psychotropic Use policy and made no changes. The facility will monitor the appropriate use of Depakote and verify that orders and documentation validate the use of Depakote. The facility will monitor the effectiveness of the Depakote and side effects will be monitored and recorded. DNS / designee will audit 20% of all PRN psychotropic medication weekly x4 weeks, then monthly x2 months. Findings will be reported to the QAPI committee.