Unnecessary Psychotropic Medication Monitoring Deficiency: A resident with dementia, anxiety disorder, and fluctuating decision-making capacity received a PRN lorazepam order for anxiety manifested by increased restlessness leading to shortness of breath, with non-pharmacological interventions listed before use. The ADON stated there was no care plan or order for monitoring the medication’s black box warning adverse effects or for behavioral monitoring to show whether the medication was effective or needed adjustment, despite the facility policy requiring monitoring and documentation of response to psychotropic meds.
Unclear indication and diagnosis for Seroquel use: A resident with dementia, anxiety, depression, and ETOH-related diagnoses received Seroquel for agitation, wandering, screaming, and mood instability, but consultant pharmacist reviews repeatedly requested clarification of the underlying diagnosis and appropriate behavior. A physician note later changed the indication to mood instability with agitated outbursts, while the MAR showed ongoing administration of Seroquel 25 mg and then 50 mg BID. Staff stated the resident should have been evaluated by psychiatry, and the DON said the psych consult was not uploaded into the EHR.
A resident with psychosis, schizoaffective disorder, depression, and anxiety received risperidone, mirtazapine, and buspirone as ordered, but the chart lacked documentation that NPIs were attempted, implemented, monitored, or found contraindicated. The care plan called for non-pharmacological approaches before medication use, and the DON confirmed the NPI order set had not been added to the resident’s chart; the PNP was unaware NPIs had not been implemented.
Psychotropic medications were not tied to specific target behaviors for two residents. One resident with dementia, depression, anxiety, epilepsy, and impaired decision-making had Depakote and clonazepam orders for irritability and restlessness, but staff said the behaviors were not specifically monitored and the care plan was not resident specific. Another resident with LBD, depression, anxiety, and epilepsy had a Fluoxetine order for depression, but the order did not identify a specific manifested behavior for staff to monitor.
PRN Ativan Continued Beyond 14-Day Limit: A resident with psychosis, dementia, and depression had a PRN Ativan order for anxiety that was written for 30 days. The DON confirmed the PRN psychotropic order exceeded the 14-day limit, and there was no documented physician reevaluation or clinical justification for continuing the medication beyond 14 days, despite the facility policy limiting PRN psychotropics to 14 days unless the attending physician documents the rationale and new duration.
Unnecessary psychotropic medication use was identified for three residents. One resident with dementia and anxiety had a PRN lorazepam order without the required 14-day limit, while another resident with dementia and behavioral disturbance received Seroquel without documented attempts at non-pharmacological interventions beyond a general care plan entry. A third resident with major depressive disorder received citalopram and zolpidem ER without documented implementation of non-drug interventions in the record, MAR, or care plan.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
A resident with schizophrenia and severe cognitive impairment received Depakote 250 mg twice daily as a mood stabilizer based on a physician order that did not specify the particular mood or behavior it was intended to treat. The DON acknowledged that psychotropic orders should identify specific, quantifiable behaviors to allow staff to monitor effectiveness and necessity, but this resident’s Depakote order lacked such detail, resulting in no behavior monitoring. Facility policy required identification and documentation of symptoms to justify antipsychotic use and stated that diagnosis alone was insufficient, yet the medication was continued without documented target symptoms or monitoring, placing the resident at risk for serious adverse effects.
A resident's record showed PRN zolpidem tartrate for insomnia was ordered for 14 days, then extended for another 14 days after the physician was notified of the resident's request. However, the chart did not include an appropriate clinical rationale for continuing the psychotropic medication beyond the original order, and an RN verified the missing documentation during record review.
The facility failed to properly monitor and document psychotropic medication use for two residents. One resident with severe cognitive impairment had orthostatic BP checks recorded with identical lying and sitting values, and the chart lacked monthly behavior summaries for mirtazapine and olanzapine. Another resident with moderate cognitive impairment had a psychiatrist’s order to discontinue clonazepam as part of a GDR, but the medication was not discontinued as ordered.
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