Failure to Monitor Antipsychotic Target Behaviors and Side Effects
Penalty
Summary
The facility failed to ensure that a resident’s antipsychotic drug regimen was monitored for target behaviors and side effects as required. A cognitively intact resident admitted with diagnoses including metabolic encephalopathy, malignant neoplasm of the colon, and non‑traumatic subarachnoid hemorrhage was receiving Quetiapine 25 mg at bedtime for bipolar disorder manifested by mood swings. The admission MDS documented verbally aggressive behaviors and antipsychotic use. A physician order dated 04/15/2025 initiated Quetiapine, but the medical record lacked documented evidence that target behaviors or side effects were monitored from 04/15/2025 through 04/28/2025, despite facility policy that residents admitted on antipsychotics be evaluated for appropriateness and indication for use by the IDT and physician. On 04/29/2025, physician orders were entered to monitor mood swings as the target behavior and to use specified non‑pharmacological interventions with outcome codes every shift, as well as to monitor for specific side effects of Quetiapine (including dry mouth, constipation, blurred vision, confusion, hypotension, EPS, and others) every shift. Interviews with an LPN and a charge nurse confirmed that Quetiapine had been administered starting 04/15/2025 and that behavior and side effect monitoring did not begin until 04/29/2025, likely because the admitting nurse did not enter the monitoring orders at the time the medication was started. The charge nurse explained that if orders are not entered into the EHR, floor nurses are not prompted to complete related tasks. The DON confirmed that the resident was not monitored for target behaviors or potential side effects from the first dose of Quetiapine on 04/15/2025 until 04/29/2025 due to the late entry of monitoring orders, despite facility policy requiring monitoring to guide decisions about continued use, dosage, and GDR of antipsychotic medications.
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