Failure to Monitor and Assess Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications and that appropriate monitoring and assessments were conducted. One resident received Depakote as a mood stabilizer without any monitoring for side effects or quarterly assessment, as confirmed by review of the clinical record and by the interim director of nursing (IDON). Another resident was also given Depakote for mood stabilization without a quarterly assessment, which was similarly confirmed by the IDON upon review of the clinical record. A third resident was prescribed multiple psychotropic medications, including bupropion, haloperidol, lorazepam, and quetiapine, for various behavioral and mood-related indications. However, there was no monitoring documented for the behaviors associated with the use of these medications. The IDON confirmed that there was no monitoring in place for these medications and acknowledged that such monitoring should have occurred. The facility's own policy requires adequate monitoring for efficacy and adverse consequences of psychotropic medications, as well as comprehensive review and evaluation of the resident's signs and symptoms prior to use.