Failure to Monitor Behaviors and Administer Medications as Ordered
Penalty
Summary
Facility staff failed to implement required behavior monitoring for residents prescribed antipsychotic and antianxiety medications, as evidenced by the absence of behavior monitoring logs or tools in the clinical records of multiple residents. For one resident with a diagnosis of bipolar disorder and a history of behavioral issues, Seroquel was administered as ordered, but there was no documentation of behavior monitoring as required by the care plan and physician order. Both the Unit Manager and DON confirmed that behavior monitoring tools should have been present in the electronic health record but were not. Another resident was prescribed Tylenol as needed for pain, with orders specifying administration for pain levels of 1-5 on a 0-10 scale. However, staff administered Tylenol even when the pain scale documented a score of 0, indicating no pain. Additionally, there were no interventions documented for pain levels of 6-10, and the Assistant DON acknowledged these discrepancies when shown the medication administration records. A third resident with multiple psychiatric diagnoses, including bipolar disorder and schizophrenia, was prescribed several psychotropic medications. The care plan required monitoring and documentation of mood and behavioral symptoms, but there was no evidence of a behavioral monitoring tool or related documentation in the resident's records. Both the Unit Manager and DON confirmed that this monitoring was not initiated as required.