Pharmacist Failed to Ensure Required Behavior Monitoring for Residents on Antipsychotics
Penalty
Summary
A deficiency was identified in the facility's process for monthly drug regimen reviews by the consultant pharmacist, specifically regarding residents prescribed antipsychotic medications. For two residents with significant psychiatric and cognitive diagnoses, the pharmacist failed to ensure that behavior monitoring was implemented and documented as required by facility policy and physician orders. In both cases, the residents were prescribed antipsychotic medications, and orders or care plans directed that specific target behaviors be identified and monitored every shift. For one resident with vascular dementia, major depressive disorder, and anxiety, the care plan and physician orders required monitoring of target behaviors related to antipsychotic use. Although the pharmacist initially recommended the inclusion of specific, objectively documented target behaviors, subsequent monthly reviews did not follow up on whether these recommendations were implemented. There was no documentation that behavior monitoring was being completed as required, and the pharmacist did not identify or address this ongoing lack of compliance in later reviews. For another resident with bipolar disorder and other psychiatric diagnoses, physician orders and the care plan required behavior monitoring for antipsychotic use. After a change in orders, behavior monitoring was not completed or documented, and the pharmacist's monthly review did not identify or recommend correction of this omission. Interviews with facility staff and the pharmacist confirmed that the required monitoring was not in place, and the pharmacist did not detect or address the deficiency during the medication regimen review.