Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not providing adequate monitoring and documentation related to the use of an antianxiety medication. The facility's policy requires that psychotropic medications, including antianxiety drugs, be prescribed, monitored, and reviewed with specific attention to indications for use, dosage, duration, and monitoring for efficacy and adverse consequences. For a resident diagnosed with bipolar disorder and depression, the clinical record showed an active order for buspirone hydrochloride to be administered three times daily for anxiety. However, the resident's clinical record and Medication Administration Records did not contain any evidence of side effect monitoring or behavior monitoring associated with the use of buspirone. Additionally, the resident's care plan did not reflect the use of the antianxiety medication, nor did it include any monitoring for side effects, identification of behaviors to monitor, or other interventions related to the medication. During an interview, the DON confirmed that monitoring and care plan documentation should have been present for the resident receiving the antianxiety medication.