Failure to Monitor for Antipsychotic Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for side effects related to the use of antipsychotic medications Risperdal and Perphenazine. The resident, a male with diagnoses including anxiety disorder, depression, and schizophrenia, was receiving both medications daily as ordered. The care plan specified that staff should monitor and document for side effects and effectiveness of psychotropic medications, listing specific symptoms to observe. However, review of the resident's orders and interviews with nursing staff, the ADON, and the DON revealed that there was no order in place for side-effect monitoring for these antipsychotic medications, despite facility policy and staff training indicating that such monitoring should be included whenever these medications are prescribed. Nursing staff and facility leadership acknowledged during interviews that the side-effect monitoring order was missing and that it should have been added when the antipsychotic medications were initiated. The facility's policy on psychotherapeutic drug management also required that side effects be documented on the Medication Administration Record. The absence of a side-effect monitoring order meant that the resident was not being systematically monitored for adverse reactions to the antipsychotic medications, as required by both the care plan and facility policy.