Failure to Monitor and Summarize Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not evaluating and summarizing the resident's behavioral symptoms for a period of five months while the resident was prescribed Seroquel for psychosis and agitation associated with dementia. The resident, who had severe cognitive impairment and required maximal assistance with daily activities, had a physician's order for Seroquel to be administered at bedtime for psychosis as evidenced by hallucinations or agitation leading to aggression. The order also required monitoring of episodes of psychosis, agitation, aggression, and hallucinations every shift. Despite these requirements, the facility did not complete the required monthly Psychotropic Drug Behavior Monitoring (PDBM) summaries from January through May. The last available PDBM summary was from December of the previous year. Both the Assistant Director of Nursing and the Director of Nursing confirmed that no behavioral symptom summaries were completed during this period and that the facility relied on these summaries to evaluate the effectiveness and necessity of the psychotropic medication. The facility's policy required adequate monitoring and documentation for the use of psychotropic medications, which was not followed in this case.