Failure to Document Indication and Monitor Sinemet Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not documenting an adequate indication for the use of Sinemet, a medication used to manage symptoms of Parkinson's disease. The resident in question had multiple diagnoses, including unspecified dementia, diabetes, atrial fibrillation, and a history of tremors, but the Minimum Data Set (MDS) did not reflect a diagnosis of Parkinson's disease, despite a physician order for Sinemet. The neurologist's consultation noted that the findings were atypical for idiopathic Parkinson's disease and that a trial of Levodopa (Sinemet) was initiated, with instructions to monitor for adverse reactions. However, there was no documentation of follow-up or monitoring for effectiveness or side effects after the medication was started. Observations revealed that the resident exhibited noticeable tremors, and interviews with nursing staff confirmed that the MDS was inaccurate and did not include the Parkinson's diagnosis. The staff member acknowledged the importance of accurate diagnosis coding and proper monitoring of Sinemet due to its potential for adverse effects. The neurologist also stated that follow-up could have occurred shortly after starting the medication, but no such follow-up was documented or communicated by the facility. Additionally, the facility's consultant pharmacist did not identify any irregularities or make recommendations regarding the use of Sinemet during medication regimen reviews from January to April. Facility policies required comprehensive assessments and medication regimen reviews to ensure appropriate use and monitoring of medications, but these were not followed in this case, resulting in the resident receiving Sinemet without adequate documentation of indication or monitoring for effectiveness and adverse effects.