Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the lack of monitoring for target behaviors, absence of nonpharmacological interventions, and missing consent for medication use in three out of five residents reviewed. For one resident with depression, records showed daily administration of an antidepressant without documentation of target behaviors or nonpharmacological interventions, and the care plan did not address these areas. A nurse supervisor confirmed that staff were not monitoring or implementing nonpharmacological approaches for this resident. Another resident with depression received an antidepressant daily, but staff did not document behavior monitoring as required, despite the care plan directing such monitoring. The resident expressed emotional distress during an interview, and a nurse supervisor acknowledged the absence of behavior monitoring documentation. A third resident with anxiety and depression was administered both antidepressant and antianxiety medications without behavior monitoring or documented consent for the antianxiety medication. Staff interviews confirmed the lack of required documentation and consent for these psychotropic medications.