Lack of Care Plan and Side Effect Monitoring for Psychotropic Medication
Penalty
Summary
A resident with a diagnosis of Major Depressive Disorder was admitted to the facility and was actively prescribed Fluoxetine, a psychotropic medication, for depression. The resident was noted to be cognitively intact and exhibited verbal behavioral symptoms directed toward others as well as episodes of rejecting care. Despite these clinical indicators and the ongoing use of a psychotropic medication, there was no care plan in place addressing the resident's depression or the use of psychotropic medication. Record review by the surveyor revealed that the facility did not document any monitoring for side effects associated with Fluoxetine. Interviews with nursing staff, including an RN and an LPN, confirmed that a care plan should have been in place for residents prescribed psychotropic medications and that side effect monitoring should be documented. However, neither a care plan nor side effect monitoring documentation was found in the resident's medical record. Further interviews with facility staff, including the Social Worker and Director of Nursing, revealed confusion and inconsistency regarding responsibility for initiating and maintaining care plans for residents on psychotropic medications. Both acknowledged that a care plan should exist for the resident's depression and medication use, but none could locate such documentation. The absence of a care plan and side effect monitoring for a resident receiving psychotropic medication constituted the identified deficiency.