Failure to Monitor Psychotropic Medication Use and Maintain Informed Consent
Penalty
Summary
The facility failed to ensure that a psychotropic medication, Trazodone, was not used unnecessarily for a resident by not monitoring the behaviors for which the medication was prescribed, not monitoring for adverse effects, and not maintaining an active informed consent for its administration. Specifically, for three consecutive days, there was no documentation of the resident's hours of sleep during the evening shift, which was required to assess the effectiveness of Trazodone prescribed for depression manifested by insomnia. Additionally, the Medication Administration Record did not show that adverse effects or side effects were being monitored as required. The resident involved had a history of major depressive disorder, moderate cognitive impairment, and required varying levels of assistance with daily activities. The responsible party for the resident was the resident's brother. The facility's own policies required written informed consent for psychotropic medications to be renewed every six months, but the resident received Trazodone for over three weeks without an active informed consent. Staff interviews confirmed the lapses in documentation and monitoring, and the Assistant Director of Nursing acknowledged the importance of these procedures for resident safety and rights.