Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor the use of psychotropic medications, specifically for one resident who was prescribed risperidone, an antipsychotic medication, for dementia. The facility's policy required the completion of a 'Behavior/Interventions' sheet or other behavior tracking form to document relevant resident data, target behaviors, the number of episodes, intervention codes, and outcomes by shift. However, a review of the resident's clinical record revealed a lack of evidence for side effect monitoring or tracking of the target behaviors that the medication was intended to address. During an interview, the Director of Nursing confirmed that there was no behavior and side effect monitoring in place for the resident's use of risperidone, despite it being a requirement. The resident's diagnoses included dementia and anxiety disorder, which necessitated careful monitoring of the effects and necessity of the psychotropic medication. The absence of such monitoring indicates a failure to comply with the facility's policy and federal regulations regarding the use of psychotropic drugs.
Plan Of Correction
1. Upon discovery, R24's behavior monitoring with the type of behavior being exhibited and the side effect monitoring were updated on the MAR. 2. A baseline audit was completed on residents receiving psychotropic medications to ensure that behavior monitoring and side effects were listed on the MAR. Education was provided by the DON/designee to the licensed clinical staff to ensure that when psychotropic medications are ordered, behavior monitoring and side effects are present on the MAR when the order is entered. 3. An audit will be conducted by the DON/designee on 5 patients on psychotropic medications weekly x 4 weeks to ensure that behavior monitoring and side effects are present on the MAR. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.