Failure to Monitor Behaviors for Psychotropic and Antipsychotic Medications
Penalty
Summary
The facility failed to implement interventions to monitor behaviors related to the use of antidepressant and antipsychotic medications for one resident. The resident, who was admitted with diagnoses including dementia, Parkinson's disease, and bipolar disorder, was prescribed multiple psychotropic and antipsychotic medications, such as Zonegran for agitation, Venlafaxine for depression, Nuplazid for hallucinations, and Mirtazapine for major depressive disorder. Review of the resident's Medication Administration Record (MAR) for July 2025 showed a lack of documentation regarding behavior monitoring associated with these medications. During interviews, the Director of Nursing (DON) was unable to locate any behavior monitoring records for the resident, either on paper or within the MAR. The absence of documented behavior monitoring for the administration of antipsychotic and psychotropic medications constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs, as required by regulation.