Failure to Monitor Behavioral Symptoms for Antidepressant Use
Penalty
Summary
The facility failed to identify and monitor specific behavioral symptoms to justify the continued use of antidepressant medications for two residents. For one resident with diagnoses including anxiety, mild dementia with mood disturbance, and depression, the medical record showed ongoing administration of mirtazapine for depression, but there was no documentation of monitoring for specific behavioral symptoms related to the medication's use. The resident's Minimum Data Set (MDS) indicated receipt of antipsychotic, antianxiety, and antidepressant medications, as well as wandering behavior, but no behavioral monitoring was recorded in the electronic medical record. Similarly, another resident with diagnoses of dementia without behavioral disturbance, chronic kidney disease, depression, and hypertension was also receiving mirtazapine for depression. The MDS for this resident indicated no behavioral symptoms, and the medical record lacked documentation of monitoring for specific behavioral symptoms to support the continued use of the antidepressant. Interviews with the Director of Nursing confirmed that the facility did not identify or monitor specific behavioral symptoms for either resident, contrary to facility policy and expectations.