Failure to Identify and Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed to residents had clearly identified target behaviors or symptoms, and did not monitor for these behaviors or symptoms to assess medication effectiveness. For example, one resident with diagnoses of seizures, anxiety, and depression was receiving antipsychotic medications for major depressive disorder, but neither the care plan nor the medical record specified individualized target behaviors to monitor. The care plan only included general interventions such as assessments, redirection, and emotional support, without detailing specific behaviors to track. The director of nursing confirmed that while weekly meetings reviewed nursing progress notes, individualized target behaviors were not documented in the medical record for residents on psychotropic medications. Similarly, another resident with dementia and anxiety was prescribed both antidepressant and antipsychotic medications, but the orders and care plan lacked evidence of specific target behaviors the medications were intended to address. Staff interviews revealed that nursing assistants and nurses were unable to identify or were unaware of any target behaviors for these medications, and this information was not reflected in the medication administration record or care plan. The facility's policy required ongoing documentation of behavioral indicators, symptoms, and monitoring for effectiveness, but this was not followed for multiple residents reviewed.