Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor the behaviors and side effects of a resident on psychotropic medications, leading to a deficiency in the resident's care. The resident, who was admitted with anxiety disorder and major depressive disorder, was prescribed Lorazepam for anxiety and Paroxetine for depression. The care plan required the facility to administer these medications as ordered and to monitor and document any side effects and the occurrence of target behavior symptoms per facility protocol. However, a review of the Medication Administration Record for December 2024 and January 2025 revealed that there was no documentation of behavior or side effect monitoring for the resident. During an interview, a Licensed Practical Nurse stated that residents on such medications are monitored for behaviors and side effects, and this information is documented in the electronic Medication Administration Record. However, when asked to provide documentation for this resident, the nurse was unable to do so. The facility's Administrator was informed of these findings, indicating a lapse in the facility's adherence to its own protocols for monitoring residents on psychotropic medications.
Plan Of Correction
Boca Circle Rehabilitation Center failed to monitor behaviors and side effects of medication. Actions Taken: 1) Resident #52's medication administration record has been updated to include behavior and side effect monitoring was implemented on Stafi L, LPN, was re-educated by the DON/Designee on to ensure medication administration records have behavior and side effect monitoring present were indicated. Others Identified: 2) A full house audit was conducted by the Director of Nursing/Designee on to ensure behavior and side effect monitoring is in place for residents receiving medications. Behavior and side effect monitoring was implemented as indicated. Measures Taken: 3) Licensed Nurses were re-educated on the components of this regulation with an emphasis on ensuring the residents on medications have behavior and side effect monitoring in place on the medication administration record. Newly hired licensed staff will receive this education during general orientation. Ongoing Monitoring: 4) The Director of Nursing/Designee will conduct weekly audits of 10 residents on each unit to verify that residents on medications have behavior and side effect monitoring in on the medication administration record weekly x 4 weeks, and then every 2 weeks x 2 months. Audit results will be reviewed in Center QAPI meeting until substantial compliance has been met.