Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to adequately monitor a resident's use of the psychotropic medication Ativan, prescribed for anxiety. The resident, who had chronic respiratory failure and quadriplegia, was admitted with intact cognition and was dependent on staff for bathing and toileting. From 5/9/2025 to 5/23/2025, the resident received thirteen 1 mg doses of Ativan for anxiety manifested by screaming and yelling due to concerns about their health condition. However, during this period, the Medication Administration Record (MAR) did not indicate that the resident was monitored for side effects of Ativan or for the presence of anxious behaviors. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that monitoring for both side effects and target behaviors was not documented after a new order for Ativan was written. The previous monitoring orders had expired, and staff failed to renew them with the new prescription. The facility's policy required daily monitoring of psychotropic drug use for adverse effects and target behaviors, but this was not followed during the specified timeframe.