Inadequate Monitoring of Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure adequate monitoring of side effects and behaviors for a resident receiving psychotropic medications. The policy titled 'Use of Psychotropic Medication' requires that residents are not given psychotropic drugs unless necessary to treat a specific condition, and the medication's effects must be documented. Resident #16, who was admitted with diagnoses including Non-Alzheimer's Dementia and a psychotic disorder, was prescribed Seroquel to address psychosis. The physician orders required behavior and side effect monitoring using a specific coding system. However, the February 2025 Medication Administration Record (MAR) showed that behavior monitoring was recorded with check marks instead of the mandated codes, failing to document the resident's response to the medication accurately. An interview with the Director of Nursing (DON) revealed that the behavior monitoring should have included coding entries as directed, and the use of check marks was not sufficient. The DON confirmed that the nurses should have recorded a zero if no behaviors were exhibited, rather than using check marks. This oversight in documentation did not comply with the facility's policy and the physician's orders, leading to a deficiency in monitoring the resident's response to the psychotropic medication.
Plan Of Correction
F757 Drug Regimen is Free from Unnecessary Drugs (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #16 had a new order for behavior monitoring was added to the resident's chart on and revised on, documentation scheduled for every shift. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. An audit was conducted of the medical records of all patients on medication to identify any without behavior monitoring on by DON/ designee. Any found without were corrected. Weekly audits will be conducted X 4 by DON or designee then monthly x 3 or until substantial compliance. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. Education provided to licensed nurses by DON by on the components of this regulation with emphasis on adequate monitoring associated medication use per physician's order requiring monitoring and the residents plan of care. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. The DON /designee will conduct quality review of 5 residents' receiving medications weekly x 4 weeks for appropriate behavior monitoring as indicated, and then every 2 weeks 2, then monthly x1 then PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months or until substantial compliance is maintained. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.