Failure to Specifically Monitor Psychotropic Medication Use
Penalty
Summary
A resident with a history of schizophrenia, muscle weakness, and type 2 diabetes mellitus was admitted and later readmitted to the facility. The resident was prescribed risperidone to treat schizophrenia manifested by paranoia, with a physician's order to monitor episodes of paranoia every shift. However, the monitoring documented in the Medication Administration Record was found to be vague and not specific to the paranoid behaviors exhibited by the resident. The registered nurse acknowledged that the monitoring lacked specificity, which is necessary to properly evaluate the efficacy and appropriateness of the medication. Facility policy requires that each resident's drug regimen be free from unnecessary drugs and that medication management includes recognition of the resident's problem, assessment, diagnosis, root cause identification, and monitoring. The failure to specifically monitor and document the resident's paranoid behaviors as required by the physician's order and facility policy resulted in a deficiency, as it could lead to inaccurate evaluation of the medication's effectiveness and appropriateness for the resident.