Failure to Provide Nonpharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to implement and document nonpharmacological interventions prior to administering psychotropic medications for three residents diagnosed with depression, anxiety, or mood disorders. Specifically, two residents received daily antidepressant medications without any documented physician orders for nonpharmacological interventions, and staff confirmed that such interventions should have been in place. Additionally, for one resident receiving both an antipsychotic and an antidepressant, there was no evidence that staff attempted nonpharmacological interventions prior to medication administration. Further deficiencies were identified in the monitoring and assessment of residents receiving psychotropic medications. For one resident on an antipsychotic, staff did not complete the required Abnormal Involuntary Movement Scale (AIMS) assessment, nor did they monitor for adverse side effects or specific target behaviors associated with the medications. Interviews with facility staff confirmed the absence of required documentation and monitoring, which was expected according to facility policy.