Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident with diagnoses including major depressive disorder, dementia, and anxiety was observed repeatedly sleeping in a wheelchair, both in her room and in a dining area. The resident had a history of severe cognitive impairment and was prescribed multiple psychotropic medications, including antidepressants and antipsychotics. Review of the resident's medical records revealed that there were no physician orders for monitoring the side effects of these medications, nor was there documentation of such monitoring on the Treatment Administration Record (TAR). The resident's care plan included interventions to monitor for side effects and adverse reactions to psychotropic medications, as well as ongoing assessment of symptoms related to depression and medication use. However, these interventions were not implemented, as evidenced by the absence of side effect monitoring orders and documentation. Interviews with nursing staff and the DON confirmed that side effect monitoring should have been in place and documented on the TAR, but this was not done for the resident in question. The facility's policy required that the interdisciplinary team assess and monitor the appropriateness, effectiveness, and side effects of psychotropic medications, with licensed nurses responsible for completing this monitoring. Despite this policy, the required monitoring was not performed or documented for the resident receiving antipsychotic and antidepressant medications, resulting in a failure to comply with established standards and the facility's own procedures.