Failure to Monitor Effectiveness of Psychotropic Medication
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident was free from unnecessary drugs by not properly monitoring the effectiveness of Ambien, a psychotropic medication prescribed for insomnia. The resident, who had diagnoses including insomnia and anxiety disorder, was admitted with cognitive skills intact and required varying levels of assistance with daily activities. Physician orders specified that the resident’s hours of sleep should be monitored every evening and night shift, particularly when Ambien was administered as needed for insomnia. Record reviews revealed that the Medication Administration Record (MAR) only included check marks for monitoring sleep, rather than documenting the specific number of hours slept as required by the physician’s order. Interviews with the resident, a Licensed Vocational Nurse, and the Assistant Director of Nursing confirmed that the MAR did not accurately reflect the number of hours of sleep, and staff acknowledged that this information was necessary to determine the medication’s effectiveness. The facility’s policy also required adequate monitoring for efficacy and adverse consequences of psychotropic medications, which was not followed in this case.