Failure to Monitor for Side Effects After Medication Error with Psychotropic Drug
Penalty
Summary
A resident with a history of hip fracture and depression, and moderate cognitive impairment, was admitted to the facility and subsequently administered divalproex sodium (Depakote), a mood stabilizing medication, in error. The resident's Minimum Data Set indicated no symptoms of mood disturbances or behavioral issues that would warrant the use of this medication. Despite this, the medication was ordered and administered for mood instability, and there was no evidence of monitoring for side effects or effectiveness during the period it was given. Interviews with facility staff, including the Facility Medical Practitioner, DON, and Facility Pharmacy Consultant, confirmed that the resident was not monitored for behavioral changes or adverse effects associated with divalproex sodium. The facility's own policies required monitoring for side effects and effectiveness of psychotropic medications, as well as monitoring after medication errors. Documentation review showed that the pharmacy consultant recommended adding monitoring, but this was not implemented, and no monitoring was documented on the Medication Administration Record.