Failure to Monitor for Side Effects of Psychoactive Medications
Penalty
Summary
Facility staff failed to monitor for side effects in residents receiving psychoactive medications. For one resident, there were active orders for Risperidone 0.5 mg daily and Sertraline 50 mg daily, both of which were administered as ordered according to the medication administration records for March and April 2025. However, a review of the clinical record did not reveal any evidence that staff were monitoring for side effects associated with these medications. Another resident was prescribed Seroquel 50 mg nightly, which was also administered as ordered during the same period. Similarly, there was no documentation or evidence in the clinical record that staff monitored for side effects related to this medication. Interviews with the DON confirmed that the facility is responsible for monitoring side effects of all psychoactive medications, and acknowledged that the facility's software sometimes triggers reminders for such monitoring, but in these cases, it had not done so. A review of the facility's policy on Psychotropic Drug Therapy did not reveal specific steps for monitoring side effects of psychoactive medications. No additional information or documentation regarding monitoring was provided prior to the survey exit.