Failure to Monitor for Antidepressant Side Effects
Penalty
Summary
The facility failed to ensure that medication side effects were monitored for a resident who was prescribed mirtazapine, an antidepressant. According to the facility's policy, the consultant pharmacist is required to perform a comprehensive monthly medication regimen review (MRR) for each resident, including evaluating responses to medication therapy and documenting any irregularities or clinically significant risks. For one resident with a history of dementia and no capacity to make medical decisions, there was a physician's order for mirtazapine to address depression and poor appetite. However, there was no corresponding physician's order to monitor for side effects of mirtazapine, and the medication administration records (MARs) did not show any documentation that side effects were being monitored. Interviews with the DON and the consultant pharmacist confirmed that monitoring for medication side effects should have occurred, but the consultant pharmacist was unaware that this monitoring was not being performed for the resident. The deficiency was acknowledged by both the Administrator and the DON during interviews, and the lack of monitoring was verified through medical record review.