Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were regularly monitored and properly documented for two residents. For one resident with diagnoses including depression, anxiety disorder, dementia with psychotic disturbance, and psychosis, the electronic health record showed missing documentation for behavior monitoring related to delusions, hallucinations, and paranoia on several dates. Additionally, side effect monitoring for both antipsychotic and antidepressant medications was either missing or not documented for multiple days, with no antidepressant side effect monitoring found for two consecutive months. Staff interviews confirmed that these omissions did not meet facility expectations for monitoring and documentation. For another resident with bipolar disorder and depression, there was no documentation of adverse side effect monitoring for a prescribed mood stabilizer. The resident was also taking an antipsychotic medication that required regular AIMS testing, but the required monitoring was not completed in a timely manner, despite a pharmacist's recommendation. Staff acknowledged that side effect monitoring and timely follow-through on pharmacist recommendations were expected but not performed in these cases.