Failure to Monitor and Document Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of residents receiving psychotropic medications, as required by physician orders and facility policy. For one resident with diagnoses including Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Anxiety, the care plan and physician orders specified the use of behavior codes to track symptoms and side effects related to antipsychotic therapy. However, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that behaviors were either not documented or only marked as '0' for no behaviors, without use of the required codes. Nursing staff confirmed that the electronic system only allowed for a yes/no response, and the Director of Nursing acknowledged that documentation was not being completed according to the specific orders. For another resident with multiple diagnoses, including dementia, psychotic disturbance, and anxiety, physician orders required the use of specific behavior, intervention, and outcome codes to monitor the effects of several psychotropic medications. Review of the MAR showed that, on multiple occasions, only check marks and nurses' initials were recorded, with no behavior codes or appropriate intervention codes documented. In one instance, an intervention code not listed in the physician order was used. The required outcome codes were also not documented, with only check marks and initials present for several days. Interviews with nursing staff indicated that they believed they were monitoring and documenting behaviors as required, but the documentation did not align with the specific codes outlined in the physician orders. The Medical Director noted the importance of monitoring behaviors and side effects for residents on multiple psychotropic medications and indicated that medication adjustments might be necessary based on such monitoring. The lack of proper documentation and monitoring represents a failure to ensure that residents' drug regimens are free from unnecessary drugs and that their mental, physical, and psychosocial well-being is being appropriately managed.