Failure to Ensure Proper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were necessary prior to administration, did not monitor the efficacy of these medications, and did not comprehensively assess residents for side effects. For one resident with severe cognitive impairment and multiple diagnoses including major depressive disorder and dementia, there was a lack of documentation regarding behaviors that would warrant the use of Ativan, as well as no record of the medication being administered or its effects, despite staff statements indicating it was given. The facility's policy required adequate indication for use and documentation of medication effects, which was not followed in this case. Another resident with diagnoses including depression, schizoaffective disorder, and anxiety had not received a quarterly Abnormal Involuntary Movement Scale (AIMS) assessment since the previous year, despite being on antipsychotic medication known to cause tardive dyskinesia. The resident exhibited behavioral issues, but there was inconsistent documentation of these behaviors to monitor the efficacy of the prescribed psychotropic medications. The Director of Nursing confirmed these lapses in monitoring and documentation, which were contrary to facility policy.