Failure to Monitor and Document Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to consistently monitor and document the behaviors of a resident with a history of schizoaffective disorder, schizophrenia, and depression, who was prescribed Depakote for mood disorder manifested by angry outbursts. According to the resident's care plan, staff were required to monitor and document episodes of angry outbursts every shift to assess the effectiveness of the medication regimen. However, behavior monitoring was discontinued on 10/14/2025 and was not reordered, despite ongoing orders for Depakote and the continued need to evaluate behavioral symptoms. Record review and staff interview confirmed that the lack of behavior monitoring meant the healthcare team did not have the necessary information to determine the efficacy of the medication or to make informed decisions about potential dose adjustments. The facility's policy required staff to observe, document, and report on the effectiveness of interventions, including antipsychotic medications, but this was not followed for the resident in question.