Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring and documentation for multiple psychotropic medications. Specifically, the resident was prescribed Valproic Acid, Hydroxyzine, and Trazodone HCL for behavioral and psychiatric symptoms, but the required behavior monitoring documentation was not present on the Treatment Administration Record (TAR). The TAR only reflected side effect monitoring for antidepressants and did not include documentation of targeted behaviors or non-pharmacological interventions, as required by facility policy and pharmacy consultant recommendations. The resident in question had a complex medical history, including vascular dementia with mood disturbance, recurrent depressive disorder, generalized anxiety disorder, and impulse disorder. The resident had a history of aggressive behaviors, multiple hospitalizations for behavioral issues, and significant cognitive impairment as indicated by a low BIMS score. Physician orders and care plans called for close monitoring of behaviors, side effects, and the use of non-pharmacological interventions, but these were not consistently documented or implemented as required. Interviews and record reviews confirmed that the TARs for several months did not document specific behaviors exhibited by the resident, such as aggression, refusal of care, or other notable actions. The documentation was limited to nurse initials and did not reflect the monitoring of targeted behaviors or the use of non-pharmacological interventions, despite clear orders and policy requirements. This lack of documentation and monitoring constituted a failure to ensure the resident’s drug regimen was free from unnecessary drugs.