Failure to Document Required Behavior Monitoring for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to document required behavior monitoring for two residents who were prescribed psychotropic medications. For one resident with diagnoses including depression, anxiety disorder, and insomnia, physician orders required monitoring for signs and symptoms of behaviors and mood related to depression, anxiety, and chronic pain every shift. However, multiple dates across several months were identified where behavior monitoring was not recorded as required. The resident was observed to be alert and reported pain and insomnia, but no changes were requested at the time of the survey. Another resident with diagnoses of schizophrenia, PTSD, bipolar disorder, and depression was also not consistently monitored as ordered. The care plan and physician orders specified behavior monitoring every shift, with instructions to document observed behaviors such as sad mood, anxiety, insomnia, aggression, and other specified behaviors. Review of the Medication Administration Record revealed numerous shifts across three months where behavior monitoring documentation was missing on both day and night shifts. Interviews with nursing staff and the Director of Health Services confirmed that it is the responsibility of the assigned nurse to complete behavior monitoring documentation each shift, as these are physician orders. Staff acknowledged that the orders are visible on the Medication Administration Record and that there was no reason for the documentation to be missed. The Director of Health Services emphasized that failure to complete the required documentation could result in communication breakdowns and lack of necessary follow-up.