Failure to Monitor Antipsychotic and High-Risk Medications with Required Lab Testing
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not appropriately monitoring antipsychotic and other high-risk medications in accordance with standard-of-care laboratory testing. The resident, who was cognitively intact but totally dependent on staff for activities of daily living, had multiple diagnoses including bipolar disorder, major depression, and hyperlipidemia, and was prescribed several medications such as rosuvastatin, aripiprazole, venlafaxine, and olanzapine. Despite these prescriptions, the resident's medical record lacked evidence of laboratory monitoring for potential side effects and treatment effectiveness of the statin, antidepressant, or antipsychotic medications since admission. Additionally, there was no documentation of pharmacy consultant recommendations for laboratory monitoring related to these medications. Interviews with facility staff, including an LPN, the DON, and the consultant pharmacist, revealed that there were no standing orders or facility policies regarding lab monitoring for medication safety, and that the consultant pharmacist did not routinely check for annual lab monitoring, relying instead on the provider to order necessary labs. The facility's policy on psychotherapeutic medications required ongoing monitoring for side effects but did not address laboratory monitoring for antipsychotic medications.