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 and did not provide adequate monitoring for these medications for three of five residents reviewed. Facility policy requires that psychoactive medications be prescribed only when medically necessary, with ongoing documentation of medical necessity, regular reassessment, and monitoring for side effects. However, clinical record reviews revealed that for multiple residents receiving psychotropic medications, there was no documentation of side effects to be observed or evidence of ongoing side effect monitoring. One resident with diagnoses of generalized anxiety disorder and depression was prescribed multiple psychotropic medications, including buspirone, sertraline, and trazodone, since admission. The clinical record lacked documentation of side effect monitoring for these medications. Staff interviews confirmed that side effect monitoring was only documented if side effects were observed, rather than as an ongoing process. Another resident with Alzheimer's disease and anxiety disorder had PRN orders for lorazepam and haloperidol without stop dates, despite a pharmacy recommendation and physician agreement to add a 14-day stop date. The order was not updated to include the stop date as required. A third resident with anxiety and depression was prescribed several psychotropic medications, including buspirone, clonazepam, sertraline, and trazodone, but the clinical record did not include identified side effects to monitor or documentation of ongoing monitoring. Staff interviews and email communication from the DON confirmed that adverse effects were only documented when they occurred, and routine monitoring was not consistently performed or documented. These findings demonstrate a failure to comply with facility policy and regulatory requirements regarding the use and monitoring of psychotropic medications.