A resident with a history of TBI, depression, anxiety, and dementia continued to receive risperidone for depression and later for a delusional disorder despite repeated assessments showing no delusions, hallucinations, or behavioral symptoms and staff and family reporting no such issues. Pharmacy reviews documented that there was no appropriate diagnosis to support antipsychotic use and that risperidone is not indicated for depression, yet the medication was continued with only one gradual dose reduction and later recommendations for further GDR declined or deferred. Although psychiatry suggested non-pharmacological interventions such as cognitive/emotion-oriented therapies, sensory stimulation, and behavior management techniques, the record contained no evidence that these interventions were developed or implemented, contrary to the facility’s psychotropic medication and GDR policy.
Surveyors found that prescribers failed to document individualized clinical rationales and to sign and date consultant pharmacist recommendations when declining suggested changes to psychotropic medications for three residents with dementia, anxiety, depression, insomnia, and psychotic disturbance. In each case, the pharmacist recommended gradual dose reductions or dose adjustments of antipsychotic, antianxiety, or sedative medications, but the declinations lacked written justification on the recommendation forms, and in two instances the forms were not signed or dated by the prescriber, despite facility policy requiring an explanation when rejecting pharmacist suggestions.
PRN psychotropic orders were left open-ended for three residents. Two residents had lorazepam orders without a stop date, including one resident on hospice, and another resident had a hydroxyzine PRN order without a stop date. The DON stated non-hospice meds should have a 14-day stop date, and hospice orders should specify the duration of hospice; the facility policy also required PRN psychotropic orders to be limited to no more than 14 days unless the prescriber documented a rationale and specific duration.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
Failure to Attempt Non-Pharmacological Interventions Before PRN Antipsychotic Use: A resident with dementia, mood disorder, and metabolic encephalopathy received PRN quetiapine multiple times for agitation, psychotic behaviors, and psychosis related to dementia. The MAR, nurse's notes, and behavior notes contained no documentation that non-pharmacological interventions were attempted before several doses, and the DON acknowledged they should have been tried first.
A resident with Alzheimer’s disease received multiple doses of PRN lorazepam for anxiety and agitation over an extended period without documentation that non-pharmacologic interventions were attempted beforehand, despite a care plan and behavioral health policy requiring such measures. On many occasions, there was no record of the specific behaviors present at the time of administration on the MAR, behavior sheets, or progress notes, and when behaviors such as yelling, agitation, and inappropriate comments were noted, there was still no evidence of attempted interventions prior to giving the medication. Staff later reported increased behaviors after the PRN order expired and indicated the resident had been receiving lorazepam routinely before meals, leading a psychiatric NP to order scheduled lorazepam BID without documented behavioral justification in the record for the period immediately preceding the change.
A resident was administered Ativan prior to dialysis treatments without adequate assessment or documentation of behavioral need, following only a single reported incident of restlessness. Facility staff did not complete required behavioral assessments or monitor the resident's response to the medication, and the responsible party was not informed of its use. The resident was observed to be alert and without negative behaviors during this period, indicating the medication was used as a chemical restraint without sufficient justification.
Two residents were affected by failures in medication management: one was given an antipsychotic injection without a current physician order, and another continued to receive antipsychotic and antianxiety medications without documented attempts at gradual dose reduction or physician-documented contraindications, contrary to facility policy and regulatory requirements.
Two residents with cognitive impairments and psychiatric diagnoses received PRN anti-anxiety medications without documentation that non-pharmacological interventions were attempted beforehand. Staff interviews confirmed that such interventions were expected, and facility policy required alternatives to be incorporated into care plans, but records did not reflect these actions.
A resident with severe cognitive impairment and multiple mental health diagnoses was prescribed Risperidone and other psychotropic medications. Despite care plans requiring monitoring for side effects, documentation showed that the last AIMS assessment was completed several months prior, with no evidence of the required quarterly assessments. Staff interviews confirmed the expectation for quarterly AIMS assessments, but the DON could not locate recent documentation.
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