Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to ensure adequate monitoring of side effects and behaviors for residents receiving medications, as evidenced by the cases of three residents. Resident #59 was admitted with diagnoses including degenerative nervous system disorder and agitation. Despite being prescribed medications for agitation and restlessness, there was no order to monitor side effects or behaviors until a later date. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that the resident received the medication as ordered, but there was no documentation of behavior or side effect monitoring until a specified date. Additionally, the care plan for Resident #59 lacked interventions to monitor for behaviors or side effects related to the medications. Resident #1, who was admitted with a diagnosis of acute diastolic heart failure and other conditions, had a care plan indicating a need for monitoring potential changes in behavior and side effects due to medication use. However, the facility failed to implement interventions to monitor these changes. The Director of Nursing (DON) stated that monitoring behaviors or side effects for these medications was not part of the protocol followed by the facility. Resident #45, admitted with a diagnosis of moderate cognitive impairment, was prescribed an antipsychotic medication. The care plan indicated the need to monitor for adverse reactions, but the MAR and TAR did not show that the facility was monitoring the side effects and adverse reactions of the medication. The DON acknowledged that there should be an order to monitor side effects, and a registered nurse confirmed that the monitoring was not documented in the electronic system.
Plan Of Correction
Resident #45 had orders clarified for monitoring of side effects of medications. Resident #1 and #59 had orders clarified for monitoring of side effects and behaviors for medications. Audit of 100% of residents with medications for side effect monitoring. Inservice all licensed nursing staff on orders to have side effect monitoring and orders with medications to have side effect and behavior monitoring. DON or designee to audit for side effect monitoring and medications for side effect and behavior monitoring weekly for 4 weeks and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.