Failure to Document Behavior Monitoring and Administer Antidepressant Medication
Penalty
Summary
The facility failed to properly document behavior monitoring and ensure the administration of prescribed antidepressant medication for a resident with diagnoses including generalized anxiety disorder and unspecified dementia. The resident had a physician order for behavior monitoring related to the use of Sertraline, but the Medication Administration Record (MAR) showed no documented behaviors through a specified date, despite Nurses Notes and Progress Notes indicating episodes of crying, suicidal ideation, and anxiety. The resident was sent to the hospital for these symptoms. Additionally, there was a lapse in medication administration, as the resident did not receive Sertraline for 22 days after the dose was reduced and the medication was not reordered until after this period. Interviews with the resident's family and the nurse practitioner confirmed that there was an intention to increase the Sertraline dose and to order a psychiatric consultation, but the medication was not administered as ordered, and there was no documented order for psychiatric services during the relevant period. The Director of Nursing acknowledged that nurses are expected to follow physician orders and that behavior notes should serve as a warning sign, but these were not acted upon appropriately in this case.