Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident was found to have active medical orders for multiple psychotropic medications, including trazodone, buspirone, and zyprexa, without any corresponding side effect monitoring orders in place. Review of the resident's medical record and medication administration records confirmed that there was no documentation of side effect monitoring for these medications. The absence of such monitoring was noted during the facility's recertification survey. Interviews with facility staff, including the Unit Manager (RN) and the Director of Nursing (DON), revealed that the facility's process requires side effect monitoring orders to be placed during admission and whenever there is a medication change. Both staff members acknowledged that the expected monitoring was not present for this resident, and the DON confirmed that the deficiency was evident in the medical record. The concern was also discussed during the facility's exit conference.