Failure to Document Behavior Monitoring for Psychotropic Medication Use
Penalty
Fine: $35,265
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure proper behavior monitoring for a resident who was prescribed psychotropic medications, specifically Seroquel and Oxcarbazepine, both administered twice daily for mood management. Record review showed that although psychiatric progress notes documented the need to monitor for agitation, aggression, combativeness, refusal of care, refusal of medications, and symptoms of depression, there was no evidence of staff behavior monitoring documented in the resident's record. During an interview, the DON confirmed that nurses are expected to document behaviors on behavior monitoring forms in the electronic medical record, but acknowledged that such documentation was missing for this resident.