Failure to Develop Care Plan for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to develop and implement a care plan for monitoring the effects of psychotropic medications for one resident with diagnoses of major depression and unspecified psychosis. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 8 out of 15, was prescribed Risperidone and Trazodone. The physician orders did not include instructions to monitor for side effects of these psychotropic medications, and a corresponding care plan was not present in the resident's records. Interviews with facility staff, including a nurse, unit manager, assistant director of nursing, and director of nursing, confirmed that there was no care plan or physician order in place to monitor for potential side effects of the psychotropic medications. The staff acknowledged that such a care plan and monitoring order should have been developed for any resident receiving psychotropic medications, but this was not done for the resident in question.