Missing stop date for PRN psychotropic medication: A resident with a seizure disorder had a PRN lorazepam IM order for seizure activity that remained active without a required stop date. The facility policy required PRN psychotropic orders to have a set duration, and staff, including an LPN/Unit Manager and the DON, confirmed the order lacked the 14-day stop date.
Missing Stop Date for PRN Psychotropic Medication: A resident received PRN Klonopin repeatedly without the required 14-day stop date. The MD order for clonazepam had no stop date, and the MAR showed multiple administrations over the review period. The ADON and DON both acknowledged the oversight and confirmed the medication should have had a 14-day stop date.
Surveyors found that the facility did not properly obtain or document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral disturbances was receiving Depakote ER for mood and agitation without any signed consent or documented risks vs benefits. A second cognitively intact resident with multiple psychiatric diagnoses was on four psychoactive medications (Klonopin, Abilify, Sertraline, Quetiapine); although a consent form was signed and witnessed due to the resident’s physical limitations, the form lacked required details such as specific drugs, dosages, frequencies, targeted behaviors, and potential side effects. A third severely cognitively impaired resident with dementia and other psychiatric conditions was receiving Valproate Sodium for behaviors without any signed consent or documented discussion of risks and benefits. The DON acknowledged that consents for these residents could not be located, despite a facility policy requiring such information and documentation before initiating or increasing psychotropic medications.
A resident with depression, anxiety, and other medical conditions received PRN alprazolam for anxiety beyond the 14-day limit required by facility policy. The order was entered with an indefinite stop date, and the medication was administered on multiple occasions past the allowed timeframe. Staff confirmed the expectation for a 14-day limit on PRN psychotropic medications, but the order and administration did not comply with this policy.
Two residents continued to receive psychotropic medications at unchanged doses despite recommendations and facility policy requiring gradual dose reductions (GDR). For one resident, lorazepam was not reduced as ordered by the Medical Director, and for another, olanzapine was not tapered despite no recent behavioral symptoms. In both cases, staff responses to pharmacist GDR requests lacked resident-specific clinical rationale, and documentation did not justify the ongoing medication regimens.
Two residents prescribed psychotropic medications did not have required behavior monitoring documented every shift as ordered by their physicians. Despite clear orders and care plans, multiple dates were identified where staff failed to record behavioral observations, and interviews with nursing staff and the DHS confirmed that this documentation is a standard responsibility for each shift.
A resident with multiple diagnoses, including mood disorder and anxiety, was administered Haloperidol for agitation without prior alternative interventions. Staff interviews revealed the resident was restrained during medication administration, despite not acting out. A recommendation for Ativan as an alternative was not followed, contributing to the deficiency.
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