Failure to Document and Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of psychotropic medications for several residents. For two residents with diagnoses such as major depressive disorder, schizoaffective disorder, hallucinations, and insomnia, physician orders required daily monitoring for side effects associated with psychotropic medications, including those with black box warnings for increased risk of suicide and other psychiatric symptoms. However, review of the Medication Administration Records (MAR) revealed that monitoring was inconsistently documented, with numerical codes used in place of descriptive entries and a lack of corresponding progress notes to detail observations. Additionally, some shifts were not signed off to confirm that monitoring had occurred as ordered. For three other residents with diagnoses including bipolar disorder, depression, major depressive disorder, agitation, and failure to thrive, physician orders for psychotropic medications also included black box warnings. Despite this, there was no evidence that side effect monitoring orders were entered into the medical record as required. Interviews with nursing staff confirmed that the responsibility for entering such orders was not consistently fulfilled, resulting in the absence of documented side effect monitoring for these residents. The facility's policy on the use of psychotropic medications requires documentation of the resident's response to medication, including progress toward goals and the presence or absence of adverse consequences. The lack of consistent documentation and failure to enter required monitoring orders for psychotropic medications with black box warnings created a situation where residents were not adequately monitored for early signs of side effects.