Failure to Implement Behavioral Health EKG Monitoring Recommendations
Penalty
Summary
The facility failed to implement the Behavioral Health Care Team's recommendation for a resident diagnosed with Parkinson's Disease, Obsessive Compulsive Disorder, and Dementia with psychotic disturbance. The resident was prescribed Seroquel, an antipsychotic medication known to have the potential to cause heart arrhythmias, which requires regular monitoring through an EKG to check for changes in the QTc interval. The Behavioral Health Nurse Practitioner recommended that an EKG be performed every six months to monitor for these potential side effects. Despite this recommendation, the resident's medical record showed that after a baseline EKG was completed prior to admission, the next EKG was not performed until 14 months later, rather than the recommended six-month interval. The Director of Nursing confirmed that a physician order for a follow-up EKG should have been implemented after the recommendation was made, but this did not occur, resulting in a failure to provide the appropriate monitoring for the resident while on Seroquel.