Failure to Monitor Behaviors and Side Effects for Residents on Psychotropic Medications and Anticoagulants
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not accurately monitoring behaviors and side effects for residents prescribed psychotropic medications and anticoagulants. Multiple residents with diagnoses such as dementia, depression, anxiety, and psychotic disorders were prescribed medications including antidepressants, antipsychotics, and anticoagulants. Despite care plans and physician orders specifying the need for monitoring of targeted symptoms, behaviors, and adverse drug reactions, there was a lack of documented evidence in the Medication Administration Records (MAR) and Treatment Administration Records (TAR) that such monitoring was performed. For several residents, including those with severe cognitive impairment and complex psychiatric and medical histories, the required monitoring for both the effectiveness and side effects of psychotropic medications was not documented. In some cases, care plans outlined specific symptoms and behaviors to be observed, such as changes in mood, appetite, involuntary movements, and signs of bleeding for those on anticoagulants. However, reviews of the MAR/TAR revealed either no documentation or only check marks indicating medication administration, without any indication that behaviors or side effects were assessed or recorded as required. Interviews with nursing staff, pharmacy consultants, and the Director of Nursing confirmed that while staff believed monitoring was being conducted and documented electronically, they were unable to provide evidence of this documentation. Additionally, pharmacy audits did not verify the presence of behavior or side effect monitoring, and staff were often unaware of the frequency or details of adverse events such as falls, which could be related to medication side effects. This lack of monitoring and documentation was consistent across all sampled residents receiving psychotropic medications and anticoagulants.