Failure to Monitor Psychotropic Medication Side Effects and Efficacy
Penalty
Summary
The facility failed to monitor the side effects and efficacy of psychotropic medications for one resident who was admitted with a history of Bipolar disorder and depressive episodes. Upon admission, the resident was prescribed clonazepam for anxiety, escitalopram oxalate for depression, and quetiapine fumarate for Bipolar disorder. Despite facility policy requiring routine review and monitoring of residents on psychotropic medications, there was no evidence that staff monitored or documented the effectiveness or side effects of these medications from the time of admission until nearly a month later. Interviews with facility staff, including the Director of Nursing Services, the South Unit Manager, and a Licensed Practical Nurse, confirmed that there was no order or documentation for monitoring the resident's psychotropic medication use prior to the later date. The medication administration records also showed that while the medications were administered as ordered, there was no documentation of monitoring for side effects or efficacy during this period. The deficiency was identified through record review and staff interviews, which revealed a lack of compliance with both facility policy and expected practice regarding psychotropic medication monitoring.