Failure to Monitor Psychotropic Medication Side Effects and PRN Use
Penalty
Summary
The facility failed to develop and implement an effective system for ongoing monitoring of side effects in residents prescribed psychotropic medications. Multiple residents were identified as receiving various psychotropic drugs, including antidepressants, antianxiety, and antipsychotic medications, without consistent or documented monitoring for adverse effects. For example, one resident reported persistent tiredness, which was attributed to her medications, but there was no evidence in her medical record or care plans that side effects were being systematically tracked or evaluated. Staff interviews confirmed that side effect monitoring was only performed after medication adjustments or by exception, rather than as an ongoing process. Another resident was prescribed as-needed (PRN) psychotropic medication without adherence to the regulatory requirement that such orders be limited to 14 days unless extended with a documented rationale from the medical provider. The resident's order for PRN lorazepam lacked a scheduled end date and did not include a supporting rationale for continued use, even though the medication was administered multiple times over several months. Interviews with facility staff and the consulting pharmacist revealed a lack of awareness or inconsistent understanding of the requirements for PRN psychotropic medication orders, particularly for hospice residents. Additional residents were found to be receiving psychotropic medications, such as antipsychotics and antidepressants, without documentation of side effect monitoring in their care plans, medication administration records, or progress notes. Staff interviews indicated that monitoring for side effects was not routinely performed unless specifically ordered or if a problem was observed. The facility's policies did not provide clear guidance on monitoring for side effects of non-antipsychotic psychotropic medications or specify where such monitoring should be documented. This lack of systematic monitoring and documentation was observed across multiple residents and confirmed by staff and leadership interviews.