Failure to Monitor and Document Psychotropic Medication Use and Interventions
Penalty
Summary
The facility failed to ensure that three out of five sampled residents were free from unnecessary psychotropic medications and that appropriate monitoring and nonpharmacological interventions were implemented as required. For one resident, staff did not monitor for specific behavioral manifestations as ordered by the physician for Risperdal, nor did they monitor for orthostatic hypotension, a known side effect of antipsychotic medication. Additionally, the number of hours the resident slept was not documented in relation to trazodone administration, with staff only placing checkmarks instead of recording actual sleep duration. Another resident was prescribed multiple psychotropic and neurological medications, including Remeron, divalproex, Nuedexta, Seroquel, and buspirone HCL, for various psychiatric and behavioral symptoms. The medical record lacked evidence that nonpharmacological interventions were attempted or provided in conjunction with these medications. Furthermore, required monthly psychotherapeutic drug summary sheets had not been completed for these medications since April, and there was no documentation that side effects for Remeron, divalproex, and Nuedexta were monitored. A third resident, who was prescribed buspirone HCL and Seroquel for anxiety and schizophrenia, also did not have documentation of nonpharmacological interventions related to these medications. Monthly psychotherapeutic drug summary sheets were not completed for this resident since April. These findings were confirmed by interviews with the RN and DON, who acknowledged the lack of required monitoring, documentation, and implementation of nonpharmacological interventions as outlined in facility policy and physician orders.