Failure to Implement Psychotropic Medication Monitoring and Care Plan
Penalty
Summary
The facility failed to implement its policy regarding psychotropic medication use for one resident. The resident was admitted with diagnoses including an intracapsular fracture of the left femur, acute respiratory failure with hypoxia, and major depressive disorder. A physician order was in place for Trazodone 100mg at bedtime for insomnia, but there were no documented orders to monitor for adverse side effects or to track the resident's hours of sleep. Additionally, the resident's care plan did not include any interventions or monitoring related to the use of Trazodone. During interviews and record reviews, both the Assistant Director of Nursing and the Director of Nursing confirmed the absence of monitoring orders and a care plan for the resident's use of Trazodone. Review of the facility's policy on psychotropic medication use indicated requirements for adequate indications, monitoring for efficacy and adverse consequences, and interdisciplinary management, which were not followed in this case. The Director of Nursing acknowledged that the policy and procedure were not adhered to.