Failure to Monitor Psychotropic Medication Use and Effects
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was properly monitored for behaviors, adverse effects, and efficacy. Medical record review showed that the resident, who had diagnoses including anxiety, depression, and hypertension, was prescribed and administered both antidepressant and antianxiety medications. The care plan required monitoring and documentation of side effects and effectiveness for these medications. However, there was no evidence in the medical record that the resident was monitored for behaviors during a specific period, and no documentation was found regarding monitoring for efficacy or adverse consequences related to the medications at any time. Further review of the medication administration records confirmed that the resident consistently received the prescribed psychotropic medications over several months. Interviews with facility staff, including the Administrator, verified the lack of documentation and monitoring for both efficacy and adverse effects, as well as the absence of behavioral monitoring until a certain date. Facility policies required such monitoring, but these were not followed in this case.