Failure to Document Psychotropic Medication Side Effect Monitoring
Penalty
Summary
The facility failed to ensure that side effect monitoring was completed and documented for a resident who was receiving psychotropic medication. According to facility policy, nursing staff are required to document the resident's response to antipsychotic medications and any side effects, including extrapyramidal symptoms or sedation, every shift. Record review showed that a resident with diagnoses of delusional disorder and unspecified anxiety disorder, and with intact cognition, was prescribed haloperidol daily. The resident's care plan specified monitoring for medication side effects every shift. However, review of the treatment administration records for two months did not show any documentation of side effect monitoring. The Director of Nursing confirmed that such monitoring should be documented in the treatment administration record and acknowledged that if it was not documented, it was not done.