Failure to Monitor Adverse Drug Effects and Provide Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not adequately monitoring medications with known adverse side effects and not providing or documenting non-pharmacological interventions prior to administering pain medications. For one resident receiving oxycodone, there was no documentation of monitoring for adverse side effects or the use of non-pharmacological interventions before administration. The resident's pain care plan did not include opioid use, monitoring for side effects, or non-pharmacological interventions, despite staff acknowledging these should have been present. Another resident receiving insulin therapy did not have documented monitoring for hypoglycemia or hyperglycemia in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), even though the care plan referenced monitoring for side effects and effectiveness. Additionally, a resident prescribed hydromorphone was not monitored for side effects, with no documentation present in the MAR or TAR. Staff interviews confirmed that monitoring for side effects and non-pharmacological interventions should have been included for these medications but were not.