Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to ensure that two residents received appropriate medication-specific monitoring for psychotropic medications, specifically antidepressants. One resident, with a history of depression and anxiety, was admitted and subsequently hospitalized after experiencing a side effect from their antidepressant medication, resulting in Syndrome of Inappropriate Antidiuretic Hormone (SIADH) and low sodium levels. Despite the resident's history and diagnosis, there was no depression symptom monitoring in place upon admission, and after a new antidepressant was started, there was no implementation of target behavior monitoring, side effect monitoring, or updates to the care plan. The resident had also initially denied depression symptoms but later disclosed ongoing depression, which was confirmed by a standardized screening tool, yet no monitoring was initiated following this disclosure. Another newly admitted resident with a diagnosis of depression was prescribed two different antidepressant medications without any associated behavior monitors, medication side effect monitors, or non-pharmacological interventions. Staff interviews confirmed that these monitoring measures were not in place for this resident. The lack of monitoring and care plan updates for both residents was acknowledged by facility staff, who stated that these components had been missed.