Failure to Monitor and Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications and that appropriate monitoring and care planning were in place during the administration of these medications. Two residents were administered venlafaxine for depression without documented monitoring for potential adverse effects. In both cases, there were no care plans developed to guide nursing staff on how to monitor for side effects or evaluate the effectiveness of the medication, and provider orders to monitor for side effects were either missing or not implemented. The Quality Assurance nurse and the Director of Nursing confirmed the absence of care plans and monitoring orders, acknowledging that staff would not have clear guidance on managing or identifying side effects. Another resident was administered Seroquel for schizoaffective disorder without the required manufacturer-specified monitoring, such as lipid panels and thyroid function tests (TSH and Free T4). The medical record lacked documentation of these assessments, and both the QA nurse and DON confirmed that the necessary monitoring was not performed or recorded. The consultant pharmacist also acknowledged that the required monitoring should have been conducted during Seroquel use. The facility's own policy required ongoing evaluation of the effects of psychotropic medications, including monitoring for adverse consequences and following manufacturer specifications. However, the records reviewed showed that these procedures were not followed for the residents in question, resulting in the administration of psychotropic medications without appropriate monitoring or care planning as required by both facility policy and clinical standards.