Failure to Monitor Behaviors and Side Effects for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring of behaviors and side effects for residents prescribed psychotropic medications, as required by both facility policy and physician orders. For three out of five residents reviewed, documentation was either unclear, incomplete, or entirely absent regarding the monitoring of behavioral symptoms and medication side effects. In one case, a resident with severe cognitive impairment and multiple psychotropic prescriptions had medication administration records that used codes not aligned with the physician's orders, and staff interviews confirmed that documentation did not clearly indicate whether side effects or behaviors were present. Another resident, who had a history of traumatic brain injury and was prescribed psychotropic medications, had no physician orders or documentation for monitoring behaviors or side effects, despite care plan interventions requiring such monitoring. Additionally, a third resident with multiple psychiatric diagnoses and several psychotropic and antipsychotic medications had physician orders to monitor for specific behaviors but lacked any orders or documentation for monitoring side effects. Provider notes for this resident specifically recommended close monitoring for side effects, sedation, or increased confusion, yet the medication administration and treatment records did not reflect any such monitoring. Staff interviews further confirmed the lack of clear or consistent documentation practices for monitoring these residents. Across all three cases, the care plans included interventions to monitor for side effects and effectiveness of psychotropic medications, but these interventions were not consistently implemented or documented. The absence of clear, consistent, and complete monitoring and documentation for residents on psychotropic medications constituted a failure to comply with both facility policy and physician orders, resulting in a deficiency related to the use of unnecessary drugs.