Failure to Monitor Psychotropic Medication Use and Indications
Penalty
Summary
The facility failed to ensure adequate monitoring for the use of psychotropic medications for two residents. For one resident with diabetes mellitus type 2 and hypertension, there was an active order for Seroquel, an antipsychotic medication, but the clinical record lacked evidence of side effect monitoring or behavior monitoring to track the targeted behaviors for which the medication was prescribed. The Director of Nursing confirmed that neither side effect nor behavior monitoring was in place for this resident. For another resident admitted with dementia and adjustment disorder with mixed anxiety and depressed mood, there was an order for Risperdal, an antipsychotic, initially documented for anxiety/agitation/combative behaviors. The order was later revised to indicate schizophrenia, despite no supporting documentation of this diagnosis in the clinical record. There was no evidence of identified behaviors, ongoing behavior monitoring, or side effect monitoring for the use of Risperdal. A pharmacist's recommendation requested clarification of the medication's indication, and the DON confirmed that the order had been corrected and that appropriate monitoring should have been initiated when the medication was first ordered.