Care Plans Lacked Non-Pharmacological Interventions for Psychotropic Medications: The facility failed to identify non-pharmacological interventions and targeted behaviors for psychotropic use in 4 sampled residents. A resident with depression and cognitive deficits, a resident with Alzheimer's disease, depression, and bipolar disorder, a resident with depression and CVA, and a resident with dementia, anxiety, depression, and psychotic disorder were all receiving antidepressant, antipsychotic, and/or antianxiety medications, but their care plans did not include the required non-pharmacological interventions or targeted behaviors. The DON stated that such interventions should be listed for antipsychotic and antidepressant medications.
A resident with anxiety, depression, and moderate cognitive impairment continued receiving quetiapine after a physician ordered it discontinued. MAR review showed the antipsychotic was still administered across multiple months, and the DON acknowledged it should have been stopped when the order was signed.
Failure to document non-pharmacologic interventions for residents receiving psychotropic medications. Three residents with diagnoses including dementia, anxiety, depression, psychotic disorder, and PTSD had care plans and behavior monitoring records that did not identify or consistently document nonpharmacological approaches before PRN or other psychotropic use. Staff interviews showed inconsistent understanding of the interventions being used, while the DON stated staff should have implemented and documented them.
Failure to Document Non-Pharmacological Interventions Before PRN Antipsychotic Use: A resident with severe cognitive loss, dementia, depression, and anxiety received PRN Haloperidol for agitation and irritability on multiple occasions, but the MAR, progress notes, and supplemental documentation did not show nonpharmacological interventions tried before administration. Staff and the DON confirmed the chart lacked the required documentation, and the facility policy stated antipsychotics should not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions.
Failure to document non-pharmacological interventions before PRN lorazepam administration. A resident with severe cognitive loss, dementia, and anxiety had a PRN order for lorazepam for anxiety/restlessness, and the care plan directed staff to try measures such as 1:1 interaction, hydration, snacks, music, toileting, and other calming interventions before giving psychotropic meds. Progress notes and the psychotropic med review did not document those interventions before multiple PRN doses, and staff interviews confirmed the missing documentation.
A resident with moderate cognitive impairment and multiple medical conditions, including atrial fibrillation, cirrhosis, arthritis, and a history of repeated falls, was prescribed PRN Lorazepam for anxiety, initially ordered every 4 hours and later changed to every 2 hours PRN without a documented rationale or end date. The MAR showed the PRN Lorazepam was given 19 times in one month, with 11 doses documented as ineffective. The DON reported that the family did not want the resident on psych meds and that staff attempted non-pharmacological interventions first, but acknowledged there was no documented rationale or end date for continuing the PRN Lorazepam beyond 14 days, contrary to facility policy requiring physician documentation for extended PRN psychotropic use.
Two residents prescribed high-risk medications did not have care plans that included required non-pharmacological interventions or targeted behaviors for monitoring. One resident's care plan lacked details for antipsychotic, psychotropic, and opioid medication management, while another resident's record did not show evidence of a required Gradual Dose Reduction for an antidepressant, despite repeated pharmacy requests.
A resident with an anxiety disorder received PRN clonazepam multiple times without staff documenting non-pharmacological interventions attempted prior to administration. The care plan lacked details on the use of anti-anxiety medication and interventions, and the facility had no policy or established process for such documentation until a recent system update.
Three residents prescribed high-risk psychotropic medications did not have individualized care plans that identified non-pharmacological interventions or specific target behaviors related to medication use. Instead, care plans contained generic statements and lacked person-centered goals and interventions, despite staff and policy expectations for individualized documentation.
A resident with dementia and multiple comorbidities received PRN antipsychotic and antianxiety medications for periods exceeding regulatory limits without required physician assessments, clinical rationales, or documentation of behavioral symptoms and nonpharmacological interventions prior to administration. Facility policy and federal guidelines for psychotropic medication use were not followed, as confirmed by review of clinical records and staff interviews.
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