Failure to Monitor Behavioral Health After Psychotropic Medication Discontinuation
Penalty
Summary
The facility failed to adequately monitor and provide ongoing assessment of a resident's behavioral health needs following the discontinuation of Seroquel, an antipsychotic medication. The resident, who had diagnoses including dementia, psychosis, and hemiplegia/hemiparesis after a cerebral infarction, was admitted with significant cognitive impairment and required extensive assistance with daily activities. After the physician discontinued Seroquel, the resident experienced multiple episodes of yelling, as documented in the Medication Administration Record over several days. However, the required weekly progress notes by licensed nurses were missing for two consecutive weeks during this period, and there was no evidence of consistent monitoring or documentation of the resident's emotional or psychosocial status after the medication change. Interviews with facility staff, including the MDS Coordinator, DON, and an LVN, confirmed that staff were aware of the need to monitor behavioral changes after discontinuing psychotropic medications and to notify the physician if behavioral issues increased. Despite this, the documentation was incomplete, and the facility's own policy required weekly progress notes to reflect the effectiveness of psychotropic medication changes and any side effects or interventions. The lack of ongoing assessment and documentation had the potential to negatively affect the resident's psychosocial well-being.