A resident with schizophrenia and other comorbidities, who was cognitively intact and reported signing their own consents, had two PRN haloperidol orders (IM and oral) written with indefinite end dates and left in place for an extended period, contrary to federal requirements and facility policy that PRN psychotropic and antipsychotic medications be limited to 14 days with documented rationale and duration for any extension. The resident reported that staff were giving medications at incorrect times, sometimes late or not at all, and that staff did not listen to concerns about medication dosing. The ADON, DON, and NP acknowledged that PRN psychotropics should be time-limited and reassessed, and facility policies specified 14‑day limits, required physician evaluation and documentation for extensions, and required informed consent and clear indication for use, but these requirements were not implemented for this resident’s PRN haloperidol orders.
PRN psychotropic meds lacked required stop dates for several residents. Orders for anxiolytic and antipsychotic meds such as alprazolam, lorazepam, Ativan, and olanzapine had no stop dates, and for some residents the EMR did not show the required 14-day assessments and new orders. The DON stated she was responsible for ensuring PRN psychotropic meds had 14-day stop dates and that the physician should be notified if longer use was needed.
A resident with dementia, anxiety, depression, and Alzheimer’s disease received multiple PRN and routine Ativan orders with inconsistent and clinically questionable indications, such as nausea related to depression and comfort related to Alzheimer’s. The MAR showed repeated PRN Ativan administrations with progress notes documenting symptoms or reasons for use on only a small fraction of doses, while nursing staff stated they did not believe separate notes were necessary and could not recall the resident’s symptoms at the time of administration. A pharmacy review form requesting action on the PRN psychotropic order, including compliance with the 14‑day CMS guideline and documentation of indication and duration, was left entirely incomplete by the prescriber. Family members reported that Ativan had previously caused an opposite, aggressive reaction at home, stated they had stopped it before admission, and said they repeatedly requested that it not be given, yet Ativan was reordered and administered several times, and they were not informed when it was discontinued and restarted. Staff, including an RN and an LPN, reported that the resident became more aggressive and violent after receiving Ativan, but the facility did not ensure appropriate review, documentation, or response to these concerns.
Unnecessary PRN psychotropic medication use. A resident with anxiety disorder and depression had a PRN lorazepam order via GT with no end date, no behaviors documented on the behavior log, and repeated administrations over the prior 3 months. The record did not include documentation supporting extension of the PRN order beyond 14 days, and the RDCS acknowledged PRN meds need an end date.
A resident with Alzheimer's dementia, severe cognitive impairment, and a care plan for potential physical aggression received PRN lorazepam for combativeness. The MAR showed the medication was given, but there were no progress notes for the day and behavior tracking showed no observable behaviors. An LPN stated she did not attempt non-pharmacological interventions before giving the PRN psychotropic, and the DON stated staff were expected to perform and document such interventions first.
Failure to assess and monitor psychotropic meds and follow a GDR order. A resident on Seroquel had no baseline assessment, and staff acknowledged a repeated behavior was not being tracked or tied to an intervention. Another resident on Lurasidone did not receive required quarterly psychotropic reviews, and a third resident’s pharmacist-recommended Mirtazapine dose reduction was not communicated to the MD/psychiatrist by the LPN/MDS Coordinator or DON.
A resident with dementia, psychotic disturbance, bipolar disorder, depression, and anxiety received Olanzapine, Citalopram, and Trazodone, but the record lacked documentation of alternatives to psychotropics, behavioral interventions, AIMS monitoring for TD, and any GDR. The care plan noted use of antianxiety, antidepressant, and antipsychotic meds, but did not include alternatives or behavioral interventions, and the Administrator confirmed the missing documentation.
A resident with a diagnosis of anxiety had a PRN order for lorazepam, a psychotropic medication, to be given every four hours as needed for anxiety without any documented duration or stop date. The facility pharmacist stated that PRN psychotropic medications require a stop date, and the facility’s psychotropic medication policy limits PRN psychotropics to 14 days unless the physician documents a rationale and specific extended duration. The absence of a stop date or defined duration on this PRN lorazepam order resulted in a deficiency.
A resident with schizoaffective disorder and other comorbidities had Seroquel doses progressively increased without documented informed consent from the resident or his guardian and without behavior documentation or evidence of non-pharmacological interventions, despite facility policy requiring these steps. The resident reported concern about receiving higher doses than expected and stated he had not consented and was refusing the medication. Behavior monitoring sheets over several months showed no behaviors, while the guardian reported concerns about the resident’s worrying and frequent calls to police and believed the dose remained at 100 mg. The ADON, psychiatrist, psych NP, and an LPN all acknowledged either the absence of documented behaviors or the requirement for informed consent and behavior documentation, which were not met.
A resident with dementia, insomnia, and a history of falls was prescribed quetiapine (Seroquel) 25 mg at bedtime for “dementia with behavioral disturbance,” despite the facility’s psychotropic policy requiring specific, documented indications and the drug reference stating it should not be used in elderly patients with dementia-related psychosis. The MDS showed the resident was cognitively intact with no documented behaviors, while the care plan listed psychotropic use for dementia with behavioral disturbance and insomnia. Staff described the resident as mainly exit seeking with lack of safety awareness, usually easily redirected, and requiring supervision at night. The DON acknowledged that antipsychotics should not be used in dementia patients and felt the resident was appropriate for dose reduction, but there was no clear, appropriate indication documented for the ongoing antipsychotic use.
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