Failure to Ensure Adequate Behavior Monitoring for Residents on Psychotropic Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure proper behavior monitoring for three residents who were prescribed psychotropic medications. The facility's policy required that behaviors be clearly documented in the medical record, included in the care plan, and reviewed at least quarterly. However, for the residents reviewed, there were inconsistencies and omissions in the documentation of behavior monitoring, as well as a lack of adherence to physician orders regarding the observation and recording of behaviors associated with medication administration. For one resident with moderate cognitive impairment and diagnoses including psychiatric conditions, the care plan and physician orders specified that staff should monitor for behaviors and document findings in the Medication Administration Record (MAR) and progress notes. Review of the MAR revealed that staff often marked boxes with an 'X' or 'Y' without specifying the behaviors, and interviews with LPNs and an RN confirmed that behavior monitoring was not consistently documented as required. Staff acknowledged gaps in documentation and were unclear about the process for recording behaviors, especially during certain shifts. Another resident with severe cognitive impairment and multiple psychiatric diagnoses had several physician orders for behavior and side effect monitoring, requiring documentation every shift. However, review of the behavior monitoring records and progress notes showed missing documentation for behaviors, interventions, or outcomes, despite orders to do so. A third resident with moderate cognitive impairment and psychiatric diagnoses also had incomplete documentation in the MAR, with some entries marked but lacking identification of specific behaviors. Interviews with staff and the DON confirmed that behavior monitoring was not performed or documented according to policy and physician orders.
Plan Of Correction
On , resident #34 was discharged from the facility. On , resident #76 was evaluated by the psych provider. No recent behaviors noted and no new orders received. On , resident #14 was evaluated by the psych provider. No recent behaviors noted and no new orders received. On , the Director of Nursing conducted a quality review of current residents who require behavior monitoring. No additional findings were noted. By , the Staff Development Coordinator educated licensed nurses on the components of F757 with an emphasis on appropriate completion of the behavior monitoring. As part of a systematic change, licensed nurses will be educated on the components of F757 with an emphasis on appropriate completion of the behavior monitoring during orientation. DON/Designee will conduct an audit of residents who require behavior monitoring weekly x 4 weeks and then 10 residents who require behavior monitoring monthly x 2 months to ensure that the behavior monitoring orders are appropriately completed by the licensed nurses. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.