Failure to Monitor and Document Psychotropic Medication Use and PRN Orders
Penalty
Summary
The facility failed to ensure ongoing monitoring and documentation of side effects and behaviors for residents receiving psychotropic medications. For multiple residents with diagnoses such as generalized anxiety disorder, depression, and dementia, there were no orders or documentation for side effect monitoring, nor was there consistent behavior monitoring as required by facility policy. Medication administration records showed that psychotropic medications were given as ordered, but there was a lack of evidence that side effects or behavioral responses were being tracked or assessed over extended periods. Additionally, the facility did not comply with the requirement to limit PRN (as needed) psychotropic medication orders to 14 days without physician re-evaluation. For at least two residents, PRN orders for medications such as lorazepam were written as indefinite and continued beyond the 14-day period without documented physician review or re-authorization. Staff interviews confirmed that these PRN orders were not discontinued or rewritten, and that documentation of behavioral indications for use and side effect monitoring was inconsistent or absent. Interviews with nursing staff and medication aides revealed a lack of clarity and consistency in the process for monitoring and documenting side effects of psychotropic medications. Staff reported that they documented by exception, only noting behaviors or side effects when they occurred, rather than conducting and recording regular assessments. There was also confusion among staff regarding which medications were considered psychotropics and what side effects to monitor, with some staff only able to identify a single side effect or medication. This lack of systematic monitoring and documentation contributed to the facility's failure to meet regulatory requirements for the safe use of psychotropic medications.