Failure to Notify Physician and Initiate Change of Condition for Ongoing Antipsychotic Side Effects
Penalty
Summary
The facility failed to meet professional standards of quality for one resident by not notifying the physician or initiating a Change of Condition (COC) when the resident experienced continuous side effects from Quetiapine, an antipsychotic medication. The resident, who had diagnoses including schizophrenia and end stage renal disease requiring dialysis, was documented as experiencing side effects such as sedation, drowsiness, and other symptoms on multiple consecutive days, as recorded in the Medication Administration Record (MAR). Despite these ongoing side effects, there was no evidence that the physician was notified or that a COC was initiated, as required by facility policy and physician orders. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the physician should have been notified and a COC initiated due to the persistent side effects. The facility's policies required monitoring, documentation, and reporting of adverse reactions to antipsychotic medications, as well as physician notification for significant changes in a resident's condition. However, these procedures were not followed, as indicated by the lack of documentation of physician notification or COC initiation, despite clear evidence of ongoing adverse effects.