Failure to Monitor Antipsychotic Use and Ensure Appropriate Psychotropic Medication Documentation
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident receiving antipsychotic medications and did not ensure that residents were free from unnecessary medications. One resident with diagnoses including Bipolar Disorder, Psychosis, Major Depressive Disorder, and Schizoaffective Disorder was prescribed Fluphenazine and Olanzapine. Although a care plan was initiated for hallucinations, anxiousness, and agitation, there was no evidence in the medical record that the resident's behaviors were being monitored as required. Staff interviews confirmed the lack of documented behavioral monitoring for this resident. Additionally, another resident was prescribed Seroquel, a psychotropic medication, with the reason for use documented incorrectly in the Medication Administration Record. The medication was listed as being prescribed for sundowning and as a supplement, which was acknowledged by the DON as inappropriate and not supported by the resident's medical diagnosis. These findings demonstrate failures in both monitoring and documentation related to the use of psychotropic medications.