Failure to Monitor Antidepressant Therapy
Penalty
Summary
The facility failed to ensure that appropriate monitoring for side effects and effectiveness was conducted for an anti-depressant medication prescribed to a resident diagnosed with major depressive disorder. The resident had a physician's order for Mirtazapine to treat depression, but a review of the clinical record did not show any evidence that staff monitored for side effects or documented the effectiveness of the medication. An interview with the Director of Nursing confirmed that no monitoring for side effects or effectiveness of the anti-depressant was performed. This lack of monitoring was identified through clinical record review and was previously cited in earlier surveys.
Plan Of Correction
Resident 35's clinical record was revised to show evidence of monitoring of side effects of the anti-depressant medication and its effectiveness. DON/Designee conducted a facility-wide audit of current residents on antidepressant medications to ensure monitoring of side effects and its effectiveness are in place. DON/Designee educated nursing staff on the importance of monitoring side effects and its effectiveness for residents on antidepressant medications. DON/Designee will randomly audit residents with antidepressant medication to ensure effectiveness and side effects are monitored. Audits will be done weekly x4 then monthly x2 or until compliance is achieved. Results will be discussed at monthly QAPI.