Failure to Monitor and Document Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality regarding the management and monitoring of psychotropic medications for two residents. Facility policy required that psychotropic medications not be administered without informed written consent, that documentation of informed consent be maintained, and that both behaviors and potential adverse drug reactions or side effects be monitored and documented each shift. For both residents, informed consent forms were present and medications were administered as ordered by the provider, but there was no evidence of monitoring or documentation of side effects as required by policy and professional standards. One resident, admitted with a diagnosis of depression, was cognitively intact and received Duloxetine and Trazodone as prescribed. The resident had signed informed consent forms listing potential side effects, and the medications were administered according to physician orders. However, there was no evidence in the medical record or care plan that monitoring for side effects of these psychotropic medications was conducted or documented, despite this being a requirement in the facility's policy. The Director of Nursing confirmed that while behaviors were monitored, side effect monitoring was not performed or documented for this resident. A second resident, also admitted with depression and cognitively intact, was prescribed Lexapro and had signed an informed consent form listing common side effects. The medication was administered as ordered, but the medical record lacked physician orders or nursing interventions for monitoring potential side effects. Nursing staff and the DON acknowledged that side effect monitoring should have occurred and been documented, but it was not. This failure to monitor and document side effects for both residents constituted a deficiency in providing care consistent with professional standards of practice.