Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident receiving aripiprazole, an antipsychotic medication, was properly monitored for side effects as required by facility policy. The policy stated that nursing staff should monitor and report side effects of antipsychotic medications to the attending physician. Review of the resident's medical record, including the Medication Administration Record (MAR) and care plan, showed that while the resident was administered aripiprazole as ordered for psychosis, there was no documentation of monitoring for medication side effects. The resident in question had a diagnosis of psychosis and was noted to have fluctuating capacity to understand and make decisions, but was assessed as cognitively intact and exhibited no behavioral symptoms such as physical or verbal aggression. The baseline care plan included interventions to monitor for adverse effects and behavioral manifestations, with instructions to notify the physician as needed. Despite these documented interventions, there was no evidence in the MAR or other records that monitoring for side effects of aripiprazole was performed or documented, as confirmed by the Director of Nursing.