Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor possible side effects and target behaviors for two residents who were prescribed psychotropic medications. Resident 53, diagnosed with dementia and hypertension, was prescribed Abilify for hallucinations. However, the monitoring for side effects was incorrectly documented as for an anti-depressant, not an antipsychotic, and did not include specific side effects such as unsteady gait and tardive dyskinesia. Additionally, there was no documented monitoring of Resident 53's targeted behaviors or hallucinations. Resident 58, diagnosed with dementia, anxiety disorder, and depression, was prescribed multiple psychotropic medications, including quetiapine, Ativan, and Cymbalta. After being hospitalized, the monitoring for potential side effects and target behaviors was not resumed upon their return. The care plan for Resident 58 did not document the use of antipsychotic medication, potential side effects, or identified target behaviors. The DON confirmed that these elements should have been included in the care plan and monitored accordingly. Interviews with the DON and NHA revealed that the facility's practice did not include documenting and tracking behaviors on a resident's Medication or Treatment Administration Record. The oversight in monitoring and documentation was acknowledged, and it was confirmed that the necessary monitoring should have been in place for both residents to ensure proper management of their psychotropic medication use.
Plan Of Correction
1. R53 potential side effects monitored for behaviors was corrected in the clinical record, care plan updated and resident continues to reside at the facility. R58's potential targeted behavior side effect is being monitored, corrected in the clinical record, care plan updated for behaviors and resident continues to reside at the facility. 2. The facility lacked evidence of side effect monitoring for the residents' individual psychotropic medications and monitoring of target behaviors for unnecessary psychotropic medications. The facility has determined that all residents prescribed psychotropic medication have the potential to be affected by this alleged deficient practice. DON is currently monitoring R53 and R58 prescribed psychotropic medication for side effects and targeted behaviors and will be conducting a facility wide audit by March 14, 2025 with the Shift Supervisors to review and ensure side effects and targeted behaviors are in place and documented in the medical record for each individual resident. 3. DON will re-educate clinical management on monitoring possible side effects and target behaviors for all residents on psychotropic medication by March 14, 2025. Routine GDR meetings are currently being held monthly by the DON, NHA, shift supervisors, medical director, IDT staff members, and Pharmacy Consultant for review. 4. The NHA, DON and Medical Director will conduct 3 random audits of at least five residents receiving psychotropic medication to ensure side effects are monitored. The audit will be conducted once a week for 4 weeks then monthly for 2 months until substantial compliance is achieved or as otherwise determined by the findings reported at the monthly and quarterly QAPI meeting until consistent compliance has been met.