Failure to Monitor Stimulant Medication Use and Effectiveness
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not adequately monitoring the use of amphetamine-dextroamphetamine, a stimulant medication typically used to treat ADHD. The resident in question was admitted with diagnoses including major depressive disorder, hypertension, and unspecified atrial fibrillation, but did not have a documented diagnosis of ADHD. Despite being prescribed amphetamine-dextroamphetamine, there was no corresponding care plan or physician’s order to monitor for adverse effects or effectiveness of the medication. During interviews and record reviews, it was confirmed that nursing staff did not create a care plan or obtain an order to monitor the resident’s behavior or potential adverse effects related to the stimulant medication. Both the registered nurse and the assistant director of nursing acknowledged that such monitoring and care planning were required by facility policy, especially for psychotropic medications. The facility’s policies also specified the need for behavioral interventions and monitoring for effectiveness and adverse consequences, which were not implemented in this case.