Failure to Monitor Psychotropic Medication Efficacy and Adverse Consequences
Penalty
Summary
A deficiency occurred when the facility failed to monitor for adverse consequences or the effectiveness of psychotropic medications prescribed to a resident. The resident, who had diagnoses including urinary tract infection, chronic respiratory failure, COPD, encephalopathy, anxiety, and insomnia, was prescribed sertraline for anxiety and trazodone for sleep. Upon review, the resident's medical record did not contain documentation of monitoring for the efficacy or adverse consequences of either medication, such as sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, photosensitivity, excess weight gain, anxiousness, or sleeplessness. The facility's policy required that each resident's drug regimen be reviewed and monitored for unnecessary drugs, efficacy, and adverse consequences, especially for psychotropic medications. Despite this, there was no evidence in the resident's Medication Administration Record or Treatment Administration Record that such monitoring was performed for the prescribed antidepressants. The deficiency was confirmed through staff interview and record review, with the Director of Nursing acknowledging that monitoring should have been completed.