Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications administered to a resident were necessary and justified, as staff did not complete required behavioral and mood monitoring documentation for the conditions these medications were prescribed to treat. A resident with diagnoses including Paranoid Schizophrenia, Major Depressive Disorder, unspecified anxiety disorder, and dementia with behavioral disturbance was receiving multiple psychotropic medications, such as Quetiapine, Valproic acid, Trazodone, and Lorazepam. There was no documented indication for Quetiapine in the physician's order, and no behavior and mood monitoring documentation was found in the resident's medical record, despite care plan interventions requiring behavior monitoring every shift and documentation of behaviors and interventions. During interviews, the DON stated that behavior monitoring was done on paper and kept in the medication administration binder, but staff were unable to produce the behavior monitoring flowsheet when requested, providing only the Treatment Administration Record instead. Additionally, a pharmacy consultant had recommended a gradual dose reduction of Trazodone, but there was no documentation that this recommendation was addressed by the psychiatry provider. These findings indicate a lack of proper documentation and follow-through regarding the use and monitoring of psychotropic medications for the resident.