Failure to Identify Lack of Target Behavior Monitoring in Psychotropic Medication Review
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified the lack of target behavior monitoring for a resident receiving psychotropic medications during the monthly medication regimen review (MRR). The resident, who had severe cognitive impairment and diagnoses including Alzheimer's disease, delusional disorders, and anxiety disorder, was prescribed paroxetine for panic disorder and quetiapine for delusional disorders. Documentation showed that target behaviors such as anxiety, agitation, and depression were only monitored for 8 out of 45 shifts in one month, and there was no evidence of target behavior monitoring in the clinical record for several months. Despite multiple monthly reviews by the pharmacist, the absence of consistent target behavior monitoring was not identified or addressed in the MRRs. The pharmacist's notes included recommendations for gradual dose reduction and monitoring for side effects, but did not note the lack of behavior monitoring. Both the pharmacist and the DON confirmed that target behavior monitoring is expected when psychotropic medications are prescribed, and the facility's policy requires the pharmacist to address irregularities during the MRR. However, this expectation was not met for the resident in question.