Failure to Monitor and Document Antipsychotic Side Effects
Penalty
Summary
The facility failed to monitor and document side effects for a resident receiving an antipsychotic medication. Facility policy on psychotropic medication use, revised February 2025, required that residents receiving psychotropic medications be monitored and that their response to treatment be documented. The resident had diagnoses including Down syndrome and dementia, and a physician’s order for risperidone 0.25 mg by mouth twice daily beginning December 2, 2025. The resident’s care plan, initiated in early November 2025, identified psychotropic medication use and included an intervention to monitor, record, and report to the physician any side effects of antipsychotic medications, listing multiple potential adverse effects such as dystonia, tremors, confusion, restlessness, anxiety, tardive dyskinesia, sedation, increased falls, and others. Review of the resident’s medical record showed no documented side effect monitoring for the antipsychotic medication, and the DON confirmed in interview that there was no side effect monitoring documented for this resident.
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