Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring for the use of psychotropic medications for a resident with severe cognitive impairment and behavioral disturbances. The resident, who had diagnoses including dementia with behaviors, impulse disorder, and psychoactive substance dependence in remission, was prescribed Depakote and later Seroquel to manage behavioral symptoms. Despite facility policy requiring monitoring for efficacy and adverse consequences when psychotropic medications are used, there was no documented antipsychotic monitoring for the resident after Depakote was initiated. The care plan indicated that monitoring, including observation for side effects and the use of the Abnormal Involuntary Movement Scale (AIMS), should be conducted, but this was not implemented as required. Interviews with the consultant pharmacist, psychiatric nurse practitioner, and medical director confirmed that behavior and antipsychotic monitoring should have been in place when the resident began receiving Depakote. The lack of monitoring persisted until after Seroquel was started, leaving a gap in oversight for potential adverse effects and effectiveness of the psychotropic medication. This failure to follow established protocols for psychotropic medication management led to the identified deficiency.