Failure to Implement Recommended Monitoring for Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to act upon a medication regimen review (MRR) recommendation for a resident receiving antipsychotic medication. The facility’s MRR policy, last updated in August 2020, states that recommendations are to be acted upon and documented by facility staff and/or the prescriber. The resident was initially admitted on 4/24/25, discharged to the hospital between 5/1/24 and 7/15/24, and then re-admitted on 7/15/25 with multiple diagnoses including dementia, anxiety, and major depressive disorder with psychotic symptoms. On 7/15/25, an admission MDS assessment documented that the resident was receiving antipsychotic medications, and a care plan was created for antipsychotic use with an intervention to monitor behaviors. Also on 7/15/25, an MRR documented that the resident’s antipsychotic required monitoring, and this recommendation was signed by the physician on 7/18/25. A physician’s order dated 7/16/25 directed that the resident receive an antipsychotic twice daily for psychosis. However, during record review and an interview on 9/26/25, an LPN confirmed that there was no ongoing monitoring intervention in place on the record, stating that there should be something based on medications every shift and suggesting it may have fallen off when the resident left and then returned. The finding was later reviewed with the NHA, DON, and corporate nurse during the exit conference on 9/29/25. This sequence of events shows that although the need for antipsychotic monitoring was identified in the MRR and acknowledged by the physician, the facility did not ensure that the recommended monitoring intervention was implemented and documented as required by its own policy.
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