Failure to Monitor and Document Anticonvulsant Side Effects
Penalty
Summary
Surveyors identified a failure to ensure residents’ drug regimens were free from unnecessary drugs by not monitoring for side effects of anticonvulsant medications as required by the residents’ care plans. One resident with major depressive disorder, anxiety disorder, and alcohol dependence had a physician order for Depakote 250 mg by mouth three times a day for alcohol dependence. The resident’s comprehensive person-centered care plan, revised 8/6/25, directed staff to monitor, notify the provider, and document specific anticonvulsant side effects, including over-sedation or lethargy, restless agitation, increased confusion or poor concentration, mental status change, visual disturbance, change in gait, behavioral changes, and weight change. Record review showed no documentation that staff were monitoring for these anticonvulsant side effects. Another resident with borderline personality disorder, Alzheimer’s disease, and suicidal ideations had a physician order for Depakote sprinkles 750 mg by mouth two times a day for borderline personality disorder. This resident’s care plan, revised 10/14/24, contained the same directives for staff to monitor, notify the provider, and document anticonvulsant side effects, listing the same potential symptoms. Record review similarly showed no documentation that staff were monitoring for these side effects. On 3/5/26 at 8:32 AM, the DON confirmed that the records for both residents did not include anticonvulsant monitoring, and the report stated this failure created the potential for harm if side effects were undetected.
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