Failure to Monitor and Document Non-Drug Interventions for Psychoactive Medication Use
Penalty
Summary
The facility failed to act upon consultant pharmacy recommendations regarding the monitoring and administration of as-needed psychoactive medications for a resident with diagnoses including malnutrition, major depression, respiratory failure, and anxiety disorder. The resident was prescribed Valium as needed for anxiety and fluoxetine for depression. The care plan required monitoring and documentation of target behaviors and symptoms related to the use of these medications, as well as the use of non-drug interventions prior to administering Valium. However, a review of the Medication Administration Records over several months showed no evidence of behavior monitoring, and progress notes did not document any non-drug interventions attempted before administering Valium. Interviews with staff, including an LPN and the DON, revealed that behavior monitoring was expected to be documented on the MAR, but in this case, it was not done. The DON acknowledged that behavior monitoring and non-drug interventions were missed for this resident. The facility's own policy required the use of non-pharmacological approaches and monitoring for efficacy and adverse consequences of psychotropic medications, but these procedures were not followed for the resident in question.