Failure to Monitor and Document Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not listing and monitoring specific behaviors for the use of psychotropic medications for two residents. For one resident with diagnoses including dementia and suicidal ideations, multiple psychotropic medications were prescribed without specific behaviors or side effects being listed for monitoring in the physician’s orders, Medication Administration Record (MAR), or care plans. Staff interviews confirmed that there was no documentation of behaviors or side effects, and the pharmacy consultant acknowledged missing this omission during the monthly medication regimen review. Another resident with diagnoses including encephalopathy and major depressive disorder was prescribed an antipsychotic medication for schizophrenia without specific behaviors being documented for staff monitoring. Interviews with staff, family, and the psychiatric nurse practitioner revealed a lack of observed or documented behaviors such as delusions, hallucinations, or violence that would justify the use of the medication. The DON and medical director both stated that there was no consistent documentation of behaviors to support the diagnosis or the use of the antipsychotic medication. Facility policies required that orders for psychoactive medications include specific behaviors to be monitored and that staff document these behaviors and any side effects. Despite these policies, the facility did not ensure that such documentation was present or that staff were monitoring and recording the necessary information to determine the continued need for psychotropic medications for the affected residents.