Failure to Monitor Antipsychotic Medications
Penalty
Summary
The facility failed to ensure proper monitoring of antipsychotic medications for three residents, R17, R21, and R40, leading to a deficiency in medication management. The facility's policy required that each resident's medication administration record (MAR) include documentation of behaviors, side effects, and efficacy of antipsychotic medications. However, the facility did not adhere to this policy, as evidenced by the lack of specific targeted behavior monitoring and side effect documentation for these residents. Resident R17, who was severely cognitively impaired, was prescribed Zyprexa for depression. Despite the care plan indicating the need to monitor for adverse side effects and efficacy, there was no evidence of specific behavior monitoring related to the use of Zyprexa. Similarly, Resident R21, who was cognitively intact, was prescribed multiple psychiatric medications, including Geodon for schizophrenia. The facility monitored general behaviors but failed to document specific behaviors or adverse reactions related to each medication. Resident R40, also severely cognitively impaired, was prescribed several antidepressants. The facility's monitoring was not specific to the medications ordered, and there was no documentation of adverse effects or efficacy. Interviews with the Director of Nursing and the Pharmacist confirmed the lack of precise monitoring for behaviors, side effects, and efficacy specific to the medications. The Registered Nurse also indicated uncertainty about where to document such observations, highlighting a systemic issue in the facility's medication monitoring practices.