Failure to Identify and Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed to a resident had clearly identified target behaviors or symptoms, and did not monitor for those behaviors or for adverse effects of the medications. The orders for multiple psychotropic medications, including an antipsychotic and two antidepressants, lacked documentation specifying the symptoms or behaviors they were intended to treat. Additionally, there was no evidence of monitoring for medication side effects, and the care plan did not include individualized non-pharmacological interventions or address the resident's hallucinations and delusional thoughts. Interviews with staff confirmed that while the resident experienced visual and auditory hallucinations, staff responses were limited to reassurance and reporting to nursing, without specific interventions documented in the care plan. The resident involved had a history of moderate cognitive impairment, functional limitations, and multiple medical diagnoses, including a neurological condition, stroke, heart failure, diabetes, and seizure disorder. Despite these complexities, the care plan and medication administration records did not identify target behaviors or symptoms for the psychotropic medications, nor did they outline how staff should respond to the resident's hallucinations. The facility's use of a standardized care plan library further contributed to the lack of individualized interventions, as confirmed by the assistant director of nursing. The facility's policy required comprehensive assessment and documentation of specific conditions for psychotropic medication use, which was not followed in this case.