Failure to Complete Required Assessments and Monitoring for Antibiotic and Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not completing required infectious screening assessments and care plans for residents started on antibiotics, and by failing to monitor behaviors and medication side effects for a resident on psychotropic medications. For three residents who were prescribed antibiotics for prophylactic purposes, there was no infectious screening assessment or care plan for antibiotic usage completed at the time the antibiotics were ordered. These assessments and care plans were only initiated after the surveyor inquired about them, despite facility policy requiring such documentation as part of the antibiotic stewardship program. The responsible staff member acknowledged the oversight and attributed it to her recent absence due to vacation. One resident was observed to be on multiple psychotropic medications, including anti-anxiety and antidepressant drugs, without any documented monitoring or recording of target behaviors or medication side effects in the Medication Administration Record (MAR). The facility’s comprehensive care plan for this resident specified that such monitoring should occur, and staff confirmed that this is the usual practice. However, no such documentation was found during the review, and staff acknowledged the omission as an oversight. The facility’s own policies require that antibiotic use be monitored and documented through infectious screening assessments, care plans, and surveillance tracking forms, and that residents on psychotropic medications have their behaviors and side effects monitored and recorded. In these cases, the required assessments, care plans, and monitoring were not completed as required by policy, affecting all four residents reviewed for unnecessary medications.