Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
Facility staff failed to ensure that two residents were free from unnecessary psychotropic medications by not monitoring for behaviors or side effects associated with these medications. For one resident with diagnoses including Bipolar Disorder, Seizures, Insomnia, Chronic Kidney Disease, Borderline Personality Disorder, and Atrial Fibrillation, there were no orders or documentation for behavior or side effect monitoring related to prescribed psychotropic medications such as Effexor, Trazadone, Depakote, and Ziprasidone during the month of March. The resident was cognitively intact, as indicated by a BIMS score of 14 out of 15, and was a new admission to the facility. The lack of monitoring was confirmed by facility leadership during the survey process. Another resident, with diagnoses including Progressive Multifocal Leukoencephalopathy, Anorexia, Chronic Kidney Disease, Acute Kidney Failure, Anxiety Disorder, Repeated Falls, Ataxia, Acute Respiratory Failure with Hypoxia, and Wasting Disease Syndrome, was also not monitored for behaviors or side effects related to psychotropic medications in April. This resident was prescribed multiple psychotropic medications, including Citalopram, Doxepin, Trazadone, and Lorazepam. The resident was cognitively intact, with a BIMS score of 15 out of 15. The April medication administration and treatment records did not include any psychotropic drug monitoring, despite the care plan indicating the need to observe and document adverse reactions. Facility policy required ongoing evaluation of the effects of psychotropic medications on residents' physical, mental, and psychosocial well-being, consistent with clinical standards and the residents' comprehensive care plans. However, in both cases, the required monitoring was not implemented or documented as required, leading to the identified deficiencies.