Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation for residents prescribed psychotropic medications, including antidepressants and antipsychotics. For one resident, an antidepressant was initiated and the dose increased, but there was no monitoring or documentation of target behaviors or potential adverse side effects in the Medication Administration Record (MAR). Staff confirmed that such monitoring and documentation were expected but missing from the records. Another resident had been on antipsychotic medication for an extended period, but the required Abnormal Involuntary Movement Scale (AIMS) assessment was completed late, exceeding the recommended six-month interval. The consultant pharmacist had previously advised the facility to document AIMS assessments every six months to remain compliant, but staff acknowledged that the assessment was overdue. Additional residents were also prescribed antipsychotic medications without evidence of monitoring for side effects or target behaviors in the physician's orders or MAR. Staff interviews confirmed that monitoring and documentation were expected for all residents on psychotropic medications, but these were not present in the records reviewed. The facility's policy required nursing staff to observe and document the effectiveness of interventions and monitor for side effects, but this was not consistently followed.