Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
A deficiency was identified when the facility failed to ensure that side effect monitoring was in place for a resident receiving multiple psychotropic medications. The resident, who had diagnoses including dementia, psychotic disorder with delusions, mood disorder, major depressive disorder, and generalized anxiety disorder, was prescribed Divalproex Sodium, Olanzapine, Lasix, Potassium Chloride, and Hydralazine. Review of the resident's records showed that behavior and antipsychotic side effect monitoring were discontinued on 06/10/25, despite ongoing use of these medications. The care plan indicated that staff should monitor and document for side effects and effectiveness, but there was no evidence of continued side effect monitoring after the specified discontinue date. During an interview, the DON confirmed that side effect monitoring should be documented in the medical record and that the admitting nurse is responsible for entering this information. The facility's medication administration policy also requires staff to report and document adverse side effects. However, the lack of ongoing documentation for side effect monitoring for this resident demonstrated noncompliance with both facility policy and regulatory requirements for unnecessary medications.