Failure to Obtain IDT Review and Behavior Monitoring for Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedure on the use of psychotropic medications for a resident who was prescribed Depakote. The resident was admitted with diagnoses including major depressive disorder, history of falling, shortness of breath, and muscle weakness. A physician order dated 1/29/26 directed that the resident start Depakote 250 mg by mouth twice daily for mixed mania and bipolar due to aggressive behaviors, and the medication was initiated that evening and continued thereafter. Record review of the Medication Administration Records (MARs) for January and February showed that the resident received Depakote 250 mg twice daily from 1/29/26 through the end of February. The January MAR indicated the resident started Depakote on the evening of 1/29/26 and continued at 8 a.m. and 6 p.m., but there was no behavior monitoring documented for Depakote use during that time. The February MAR showed that behavior monitoring related to Depakote was not initiated until 2/11/26, despite the resident having been on the medication since 1/29/26. During an interview and concurrent electronic medical record review with the Social Services Director, it was confirmed that the resident was started on Depakote 250 mg twice daily without an Interdisciplinary Team (IDT) meeting having been conducted to determine the appropriateness of initiating this psychotropic medication. The Social Services Director stated that staff were supposed to monitor the resident’s behaviors while on Depakote to determine if the medication and dosage were appropriate, but this was not done initially. The facility’s policies on Use of Psychotropic Medications and the Psychotropic Drug Committee require adequate indications for use, evaluation of nonpharmacological interventions, IDT involvement, and documentation of the resident’s response to psychotropic medications, which were not implemented for this resident at the time Depakote was started and during the initial period of its administration.
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