Failure to Monitor and Document Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor and document behaviors and side effects for residents receiving psychotropic medications, as required by both facility policy and physician orders. For three out of five sampled residents, there were multiple instances where behavior and side effect monitoring was not documented on the required flow sheets or medication administration records. This lack of documentation occurred despite clear orders and care plan interventions that specified monitoring and reporting of any changes in mood, behavior, or side effects related to psychotropic medication use. One resident with severe cognitive impairment and multiple psychiatric diagnoses had several shifts with missing documentation of behavior and side effect monitoring, even though orders required this to be completed every shift. Another resident, who was cognitively intact and prescribed antidepressants, also had several days in which there was no documented evidence of medication management or monitoring for side effects. A third resident, with diagnoses including anxiety and depression, had missing documentation for anti-anxiety intervention codes and behavior monitoring on several shifts, despite being prescribed both antidepressant and anti-anxiety medications. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the expectation was to monitor and document behaviors and side effects for all residents on psychotropic medications every shift. However, staff acknowledged that there were multiple instances where this documentation was not completed as required. The failure to consistently monitor and document these parameters represents a deficiency in ensuring that residents' drug regimens are free from unnecessary drugs and that adverse effects are promptly identified and addressed.