Failure to Monitor and Document Antipsychotic Side Effects
Penalty
Summary
The facility failed to monitor and document the side effects of antipsychotic medication for a resident diagnosed with conditions including cerebrovascular disease, schizophrenia, hypothyroidism, dementia, and drug-induced dyskinesia. The resident was prescribed Paliperidone, an antipsychotic, and her care plan included interventions to observe and report side effects such as sedation, headaches, dizziness, and other symptoms. However, a review of the resident’s medical record, including medication and treatment administration records from January through April 2025, revealed no documented evidence of daily monitoring for antipsychotic side effects as required by the care plan and facility policy. Interviews with the DON and ADON confirmed that daily documentation of side effect monitoring for antipsychotic medications was expected and should be present in the medical record, but was missing for this resident. The facility’s policy on behavior management also emphasized the importance of describing behaviors that could indicate medication side effects. This deficiency was identified during a complaint investigation and had the potential to affect other residents receiving antipsychotic medications.