Failure to Complete Sleep Assessments and Monitoring for Residents on Melatonin
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was developed and implemented for residents prescribed sleep aids, specifically melatonin. Three residents who were prescribed melatonin for sleep-related issues, such as difficulty sleeping, sleep hygiene, and insomnia, did not have a sleep assessment completed or any sleep monitoring documented in their medical records. This lack of assessment and monitoring was identified through both interview and record review. The facility's policy on the use of psychotropic medications requires a documented clinical rationale for medication use, including an assessment of the resident's condition, evaluation of non-pharmacological approaches, and ongoing documentation of the resident's response to the medication. Despite these policy requirements, the Director of Nursing confirmed that sleep assessments and monitoring were not routinely conducted for residents taking sleep aids, resulting in the absence of necessary documentation and evaluation for the affected residents.