Date of Graduation
Winter 12-12-2025
Document Access
Project/Capstone - Global access
Degree Name
Master of Science in Nursing (MSN)
College/School
School of Nursing and Health Professions
Program
MSN project
First Advisor
Tania Borja-Rodriguez PhD, RN, FNP-BC
Abstract
Psychotropic medications are routinely prescribed in skilled nursing facilities to manage behavioral and psychological symptoms, but inadequate documentation poses risk to patient safety and leads to regulatory noncompliance. Objective: This project aimed to improve nursing staff knowledge and confidence in documenting psychotropic medication use in order to safeguard patient safety and follow Center for Medicare and Medicaid Services (CMS) guidelines. Aim: A targeted education session and standardized flowsheets were developed to enhance documentation adherence and staff confidence in psychotropic medication administration. Methods: To assess knowledge, comfort, and adherence to documentation standards a pre- and post-intervention survey were administered to nursing staff. Results: Results showed that staff reported feeling more confident and knowledgeable about documentation, and adherence to medication protocols improved. For example, the number of staff reporting being “slightly confident” dropped from 56% to 0%, while “moderately confident” responses rose to 56%. Conclusions: Focused education combined with structured documentation tools supports nursing staff competency, promotes resident safety, and strengthens compliance with federal and state regulations. Ongoing training, chart audits, and electronic health record (EHR) review are recommended to maintain these improvements and offer a model for quality improvement in skilled nursing facilities.
Recommended Citation
Williams, Dyani, "Beyond Compliance: How Targeted Education Improves Psychotropic Medication Documentation and Patient Safety in Skilled Nursing Facilities" (2025). Master's Projects and Capstones. 1987.
https://repository.usfca.edu/capstone/1987
