Failure to Implement Targeted Behavior Monitoring for Antipsychotic Use
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement targeted behavior monitoring for a resident who was started on an antipsychotic medication. The resident had diagnoses including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and an admission MDS BIMS score of 10/15 indicating some memory recall deficits. On 12/23/25, a psychiatric APRN documented concerns about possible undiagnosed bipolar disorder, depression, or significant trauma history and ordered a trial of Abilify 2 mg daily for delusional disorder. Facility policy dated 06/2019 required that residents receiving antipsychotic medications have specific target behaviors identified and monitored every shift, and that a behavior flow sheet be initiated any time a resident is started on an antipsychotic. Despite these requirements, review of the December 2025 eMAR showed no documentation that targeted behaviors were monitored every shift after Abilify was initiated. On 1/2/26, the psychiatric APRN documented that the resident continued to exhibit restlessness and yelling out and increased the Abilify dose to 5 mg daily for psychosis, with additional behaviors of concern including avolition and impulsiveness. Review of the January 2026 eMAR again failed to show targeted behavior monitoring every shift related to the Abilify use. In interviews, the psychiatric APRN stated that behavior monitoring should have been implemented upon initiation of Abilify, including monitoring restlessness, impulsiveness, delusions, hallucinations, and paranoia. The DON and a Regional Nurse (RN #7) also confirmed that targeted behavior monitoring should have been initiated when the Abilify order was started and that Nursing Supervisors or Nursing Administration who confirmed the order should have ensured an order for targeted behavior monitoring was put into place.
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