Failure to Monitor for Adverse Effects of Carbidopa-Levodopa
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not monitoring for adverse effects associated with carbidopa-levodopa, a medication prescribed for Parkinson’s Disease. The resident’s care plan specifically identified the risk of adverse effects, such as dyskinesia, and directed staff to monitor for these effects and alert the physician as needed. However, a review of the Medication Administration Record (MAR) for the relevant period showed no documentation of such monitoring. Interviews with both a registered nurse and the Director of Nursing confirmed that monitoring for adverse effects should have been documented on the MAR, in accordance with the care plan. Both staff members were unable to locate any evidence of monitoring for adverse effects related to carbidopa-levodopa during the specified timeframe. The lack of documentation indicated that the care plan was not implemented as intended, and the resident’s needs were not adequately addressed. The facility’s policies and procedures required monitoring for adverse consequences of medications and prompt reporting of any such events. The policies also specified that licensed nurses should review drug regimens for adequate monitoring and that adverse consequences should be minimized by following clinical guidelines. Despite these requirements, the facility did not ensure that monitoring for adverse effects of carbidopa-levodopa was performed or documented for the resident, resulting in a failure to comply with both internal policy and regulatory standards.