F0757

E

Failure to Monitor Target Behaviors for Residents on Antipsychotic Medications

Meriden, Connecticut Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents receiving antipsychotic medications had their targeted behaviors monitored as required, resulting in drug regimens that were not adequately evaluated for necessity. For one resident with bipolar disorder, depressive episodes, and Alzheimer’s disease, the care plan identified antipsychotic use (Aripiprazole) with interventions to observe for excessive crying and suicidal ideation. Physician orders showed dose changes over time, but the January and February 2026 Medication Administration Records (MARs) did not contain documentation that these targeted behaviors were monitored every shift in relation to the antipsychotic use.

A second resident with schizophrenia, major depressive disorder, and anxiety disorder was prescribed Clozaril for schizophrenia, with a care plan directing observation for paranoia, delusions, and hallucinations. A third resident with dementia with behavioral disturbances and a cognitive communication deficit was prescribed Rexulti for dementia with behavioral disturbances, and the care plan required observation for targeted behaviors related to psychotropic use. For both of these residents, review of the January and February 2026 MARs failed to show that specific targeted behaviors were monitored every shift. The psychiatric APRN stated that all residents on antipsychotic medications should have behavior monitoring in place upon initiation of the medications, and the DON confirmed that targeted behavior monitoring should have been implemented every shift for these residents. Facility policies on psychotropic medication use and behavioral assessment required monitoring for efficacy, adverse consequences, and behavioral symptoms, but the required behavior monitoring and documentation were not carried out as specified.