Date of Award
Summer 2026
Document Type
Dissertation
Abstract
Background: Psychotropic medications are commonly used in long-term care (LTC) settings; however, incomplete documentation of medication necessity, monitoring, nonpharmacological interventions, and informed consent can contribute to regulatory noncompliance and increased risk for deficiency citations.
Objective: The purpose of this project was to improve psychotropic medication documentation compliance in a LTC facility among licensed nursing staff through a targeted educational intervention.
Method: A quality improvement project using a pre- and post-intervention design was conducted in a 122-bed LTC facility in the Southeastern United States. Licensed registered nurses and licensed practical nurses received mandatory targeted education on objective behavioral documentation, nonpharmacological interventions, psychotropic medication justification, monitoring, and informed consent requirements. Compliance was measured through retrospective chart audits completed before and after implementation using an audit tool, supported by the regulatory standards set by the Center of Medicare and Medicaid Services (CMS). Documentation compliance rates were compared to evaluate project outcomes.
Results/Findings: Documentation compliance across psychotropic medication documentation elements improved from 19.2% (10/52 compliant records) pre-intervention to 70.2% (33/47 compliant records) post-intervention, representing a 51.0 percentage-point increase. Improvements in documentation compliance were observed for medication indication, nonpharmacological interventions, target symptom and treatment effectiveness monitoring, informed consent, and side-effect monitoring. Statistical analysis demonstrated a significant association between the educational intervention and improved documentation compliance, χ² = 26.12, p < .001.
Conclusion: Targeted nurse education was effective in improving psychotropic medication documentation compliance in the LTC setting. Findings support the use of targeted education, audit-feedback processes, and ongoing performance monitoring as sustainable strategies to enhance regulatory compliance, survey readiness, interdisciplinary communication, and the safe management of psychotropic medications among LTC residents.
Recommended Citation
Kizzire, Allison B., "Educating for Accuracy: An Initiative to Improve Clinical Documentation Compliance of Psychotropic Medication Use in Long-Term Care" (2026). Dissertations. 13.
https://roar.una.edu/dissertations/13
Included in
Behavioral Medicine Commons, Community Health Commons, Community Health and Preventive Medicine Commons, Geriatrics Commons, Health Services Administration Commons, Health Services Research Commons, Interprofessional Education Commons, Medical Pharmacology Commons, Mental Disorders Commons, Nervous System Diseases Commons, Neurology Commons, Neurosciences Commons, Nursing Administration Commons, Other Psychiatry and Psychology Commons, Other Public Health Commons, Palliative Care Commons, Patient Safety Commons, Pharmaceutics and Drug Design Commons, Pharmacy Administration, Policy and Regulation Commons, Physiological Processes Commons, Psychiatric and Mental Health Commons, Psychiatric and Mental Health Nursing Commons, Psychiatry Commons, Psychological Phenomena and Processes Commons, Public Health and Community Nursing Commons, Public Health Education and Promotion Commons, Quality Improvement Commons, Rural Health Commons, Social Work Commons
