F0605

D

Failure to Monitor and Document Psychotropic Medication Side Effects

Broken Arrow, Oklahoma Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The facility failed to ensure ongoing side effect monitoring for a resident receiving a psychotropic medication. Facility policy on monitoring and reduction of unnecessary medications required staff to proactively monitor medication side effects, document findings, and collaborate with providers to adjust or discontinue medications when appropriate. A physician’s order dated 08/29/25 directed that Resident #19 receive fluoxetine 10 mg PO daily, and a quarterly assessment dated 12/12/25 documented that the resident, who had a BIMS score of 12 indicating moderate cognitive impairment, routinely received an antidepressant. The resident’s care plan, dated 12/31/25, included an intervention for depression specifying that medications were to be administered as ordered and that side effects and effectiveness were to be monitored and documented. However, review of the treatment administration record from 08/29/25 through 02/10/26 revealed no documentation of side effect monitoring, and on 02/11/26 the DON confirmed that no side effect monitoring had taken place for this resident.

This deficiency involved one of five sampled residents reviewed for unnecessary medications, and the DON identified that 60 residents in the facility were receiving psychotropic medications.