Failure to Monitor and Document Effects of Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor and document the effects of psychotropic medications for a resident with multiple diagnoses, including bipolar disorder, dementia, and insomnia. Physician orders required staff to monitor for side effects such as over-sedation, lethargy, mental status changes, and changes in mobility. Despite these orders, there was no documentation in the resident's Medication Administration Record (MAR) regarding sedation or lethargy, even though the resident was observed multiple times falling asleep during activities, at meals, and while standing in her doorway. The resident also appeared unkempt and disheveled, with staff noting that her condition was not being documented. Observations included the resident falling asleep at a table during activities, at lunch after only a few bites, and while leaning on her doorway. The resident's care plan directed staff to monitor and report changes in cognitive function, but these changes were not documented. The Director of Nursing confirmed that staff were not documenting the resident's condition, making it unclear if medication adjustments were needed. This lack of monitoring and documentation resulted in the resident not being adequately assessed for potential chemical restraint or unnecessary medication use.