Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for side effects and behaviors associated with psychotropic medications. The resident in question had multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, kidney failure, unspecified dementia with behavioral disturbance, and a history of substance abuse. The resident's care plan included interventions to administer medications as ordered and to monitor and document for side effects and effectiveness, as well as to review medications for possible causes of cognitive deficits. Despite these care plan interventions, a review of the Medication Administration Record (MAR) for April and May 2025 showed no documented evidence that staff monitored for side effects and behaviors every shift for the antipsychotic and antianxiety medications prescribed to the resident. This lack of documentation was confirmed during an interview with the Regional Director of Clinical, who acknowledged that there was no evidence of monitoring for the specified periods. The failure to monitor and document as required led to the cited deficiency.