Failure to Monitor Antidepressant Side Effects and Behaviors
Penalty
Summary
A resident with diagnoses of dementia and major depressive disorder was admitted to the facility and prescribed Fluoxetine 10 mg daily for depression. The resident was moderately cognitively impaired, requiring supervision and assistance with activities of daily living. The care plan included goals to observe for changes in mood and behavior and to record these on a behavior tracking form. However, review of the treatment plan revealed a lack of documentation regarding monitoring for side effects or behavioral observations related to the antidepressant medication. During a record review and interview, a registered nurse confirmed that there was no physician order for behavioral monitoring associated with the Fluoxetine prescription. It was also noted that the resident frequently refused her medications, with the last administration recorded several days prior. The electronic record showed no evidence of behavioral monitoring for this resident, and the nurse agreed that such monitoring should have been in place.