Failure to Implement Resident-Specific Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to ensure that staff implemented resident-specific interventions for the use of psychotropic medications for one resident with severe cognitive impairment and multiple psychiatric diagnoses, including schizophrenia and adverse effects from antipsychotics. The resident's care plan required staff to observe and report adverse reactions to psychoactive medications, such as lethargy, fatigue, and drowsiness. Despite these requirements, the clinical record showed that the resident experienced increasing lethargy, weakness, poor appetite, and difficulty maintaining an upright position over several days following an increase in psychotropic medication dosage. Staff documented multiple episodes of the resident being lethargic, having periods of apnea, poor oral intake, and difficulty responding to questions or maintaining posture. Bruising was also noted, and the resident required increased assistance with activities of daily living. Although staff noted these changes and attempted to contact the resident's power of attorney and physician, there was a delay in escalating care and notifying the psychiatric ARNP who managed the resident's medications. The ARNP later confirmed that she had not been notified of the resident's condition change during the relevant timeframe. The facility's policy required appropriate administration, evaluation, and monitoring of psychotropic medications in collaboration with the interdisciplinary team. However, the documentation lacked evidence that the psych ARNP was informed of the resident's significant change in condition after the medication increase, and staff did not consistently implement the care plan interventions for monitoring and reporting adverse reactions. This failure contributed to a delay in addressing the resident's deteriorating condition.