Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use, specifically Ativan, by not providing a specific indication for its use and not monitoring for manifested behaviors or side effects as required by facility policy and care plan. The resident in question had multiple diagnoses, including congestive heart failure, dementia, and diabetes mellitus, and was assessed as having severely impaired cognitive skills and being dependent on staff for all activities of daily living. The care plan indicated the resident had episodes of agitation and anxiety, with interventions to administer medications as ordered and monitor for side effects and effectiveness, as well as to document behaviors and potential causes. Record reviews revealed that the physician's order for Ativan lacked a specific manifested behavior for restlessness, which was necessary for accurate monitoring and administration. Interviews with the DON, LVN, MDS Nurse, and ADON confirmed that the order did not specify the required behavioral manifestations, and that staff did not document or monitor the resident's specific behaviors or side effects associated with Ativan use. The Medication Administration Record (MAR) and Monthly Psychoactive Drug Management (MPDM) forms did not reflect any monitoring for the resident's behavior or side effects during the period when Ativan was administered. Facility policies required that any order for psychoactive medications include a specific behavior manifestation and that residents be monitored for side effects and adverse consequences, with all occurrences documented monthly. Staff interviews and record reviews confirmed that these policies were not followed, resulting in incomplete and inaccurate documentation regarding the resident's behavior and medication use. This failure to follow established protocols led to the deficiency cited in the report.