Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were monitored for side effects, as required by their policy. This deficiency was identified for three residents. Resident 37, diagnosed with major depressive disorder with severe psychotic symptoms, was prescribed Aripiprazole, an anti-psychotic medication, but there was no evidence of monitoring for side effects from January 23, 2025, to April 23, 2025. Similarly, Resident 43, who has anxiety disorder and major depressive disorder, was prescribed Risperidone, another anti-psychotic medication, but was not monitored for side effects from April 3, 2025, to April 23, 2025. Resident 59, with diagnoses including anxiety disorder, schizophrenia, and depression, was prescribed multiple psychotropic medications, including Olanzapine, Rexulti, Remeron, Sertraline HCL, and Clonazepam. However, there was no evidence in the clinical records that Resident 59 was monitored for side effects of these medications. The Director of Nursing confirmed that these residents were not monitored for side effects from the use of antipsychotic medications, which is a violation of the facility's policy and regulatory requirements.
Plan Of Correction
1. Facility cannot retroactively add in monitoring of psychotropic medication side effects for resident 37, resident 43 and resident 59. 2. Current residents receiving psychotropic medications are at risk to have side effects monitoring of psychotropic medications. Facility performed an audit to ensure those residents on psychotropic medications have side effect monitoring included in clinical records. 3. DON, or designee, will educate licensed nursing staff on ensuring residents on psychotropic medications have orders for monitoring side effects. 4. DON, or designee, will perform weekly audits for 2 weeks, then monthly for 2 months to ensure side effects monitoring is being completed on psychotropic medications. Results of audits will be submitted to monthly Quality Assurance and Improvement Plan meetings for review and recommendations.