Failure to Adequately Monitor and Document Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring of antipsychotic medication for a resident admitted with a diagnosis that included delirium. The resident had physician orders for Quetiapine, an antipsychotic, with instructions to monitor for specific side effects every shift and to document 'Y' if side effects were observed and 'N' if not. However, review of the Medication Administration Records (MAR) for February and March showed that staff used check marks instead of the required 'Y' or 'N', making it unclear whether side effects were observed or not. Interviews with nursing staff and the Director of Nursing Services confirmed that the documentation system was not followed as intended, and the check marks did not indicate if the resident experienced any side effects from the antipsychotic medication. This lack of clear documentation failed to meet the requirement for monitoring and documenting potential adverse effects of unnecessary drugs, as specified by facility policy and regulatory standards.