Failure to Implement Behavior Monitoring for Antipsychotic Use
Penalty
Summary
The facility failed to implement behavior monitoring for a resident who was prescribed antipsychotic medication. Medical record review showed that the resident was admitted with a diagnosis of bipolar disorder and had a physician's order for risperidone. Psychiatry consult notes indicated the resident was stable, with no reports of sleep disturbances, appetite changes, suicidal or homicidal ideation, hallucinations, or delusions, and no observed agitation or aggression. The psychiatrist's plan included considering a gradual dose reduction or discontinuation of risperidone if stability continued. However, review of the Treatment Administration Record revealed that behavior monitoring, which is required for residents receiving antipsychotic medications, was not documented. The Director of Nursing confirmed that the behavior monitoring tool was not used, which was necessary for the psychiatrist to make informed decisions regarding medication management.