Failure to Monitor Target Behaviors for Medication Used to Treat PTSD
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not monitoring target behaviors for a medication prescribed to treat Post Traumatic Stress Disorder (PTSD). The resident, who had a history of chronic respiratory failure with hypercapnia and PTSD, was prescribed Prazosin to address night terrors associated with PTSD. Although the physician’s order specified that the medication was for night terrors, there was no documented evidence in the resident’s medical record that these target behaviors were being monitored as required. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that Prazosin, while not classified as a psychotropic medication, was being used off-label for a psychiatric diagnosis and should have been monitored for effectiveness and adverse effects. Both the ADON and DON acknowledged that the resident’s night terrors, the target behavior for the medication, were not being tracked. The facility’s policy required monitoring and documentation of residents’ responses to psychotropic medications, including symptoms, behaviors, and side effects, but this was not followed in this case.