Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications for two residents. For one resident with a history of left hip fracture, diabetes mellitus, and chronic kidney disease, physician orders included antianxiety, antipsychotic, and antidepressant medications. The antipsychotic medication order lacked an associated diagnosis, and the clinical record did not contain documentation of non-pharmacological interventions, monitoring for effectiveness of pharmacological interventions, or evidence of side effect or behavior monitoring as required by facility policy. The care plan referenced monitoring and documentation, but the clinical record did not reflect these actions. Another resident with dementia, a history of falls, and dysphagia was prescribed antianxiety and antipsychotic medications. The clinical record for this resident also lacked documentation of non-pharmacological interventions, effectiveness of pharmacological interventions, and monitoring for side effects or behaviors. During staff interviews, it was confirmed that the required clinical documentation and monitoring were not present for these residents, and that one antipsychotic medication order did not include a diagnosis.