Failure to Document Target Behaviors and Side Effects for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not identifying and documenting target behaviors and/or side effects of psychotropic medications for four residents. Clinical record reviews revealed that care plans and electronic medication administration records (EMARs) did not specify the target behaviors for which antianxiety, antidepressant, and antipsychotic medications were prescribed, nor did they consistently document the side effects to be monitored. This deficiency was observed in residents with a range of cognitive abilities and psychiatric diagnoses, including severe cognitive impairment, anxiety, depression, schizophrenia, PTSD, and other mental health conditions. The care plans and EMARs lacked individualized information, often containing only general orders from admission without subsequent updates to reflect specific behaviors or side effects related to each medication. Staff interviews indicated a lack of awareness and understanding among certified nursing assistants (CNAs) and medication aides regarding where to find information about target behaviors and medication side effects. Several staff members reported relying on word of mouth or general knowledge of residents’ usual behavior rather than documented, individualized information. Some staff stated that behaviors would be documented if observed, but there was no clear process for linking specific behaviors or side effects to particular medications in the care plans or EMARs. The care plan coordinator and DON acknowledged that while behaviors were being added to care plans, they were not specifically related to medications, and that the process of updating records to include individualized information was incomplete. The facility’s own policy required the identification and documentation of behavioral symptoms, individualized interventions, and monitoring for medication efficacy and adverse effects. However, the policy was not followed, as evidenced by the lack of detailed documentation in both care plans and EMARs for residents receiving psychotropic medications. This failure to document and monitor target behaviors and side effects as required contributed to the deficiency identified during the survey.