A resident had an active PRN order for Hydroxyzine 10 mg q12h for anxiety that remained in place beyond the 14-day limit without a provider-documented rationale. The DON stated PRN psychotropic orders should be limited to 14 days unless the provider documented the extended need, and the facility policy reflected the same requirement.
A resident with LBD, Parkinson's disease, anxiety, and depression was prescribed clozapine twice daily and clonazepam at bedtime without adequate documented clinical indication. The PNP stated clonazepam should be used for schizophrenia or anxiety, but review of the attending provider's documentation and PMH showed no dx or clinical documentation of schizophrenia to support the antipsychotic and benzodiazepine regimen.
A resident received Risperdal with inconsistent documentation supporting schizophrenia or psychosis, and the chart showed frequent changes in dose and indication without proper assessment or timely documentation. MDS coding, psych notes, and provider entries conflicted over whether schizophrenia was present, while the DON validated the lack of proper documentation for the antipsychotic regimen.
A resident was administered quetiapine and PRN lorazepam for behavioral symptoms without proper documentation of behavior monitoring, nonpharmacological interventions, or attempts at gradual dose reduction. The PRN psychotropic order lacked a required 14-day stop date, and the consent for psychotropic use was signed on admission without evidence of exhausted nonpharmacological approaches. Staff interviews confirmed inadequate documentation and inappropriate diagnoses for medication use.
Two residents were administered additional or continued psychotropic medications without documented attempts at non-pharmacological interventions or timely response to pharmacy recommendations for gradual dose reduction. Staff and medical director interviews confirmed the lack of documentation and intervention prior to medication changes.
A resident receiving hospice care had their Lorazepam dose increased without documented clinical justification in the medical record. Despite multiple changes to the psychotropic medication regimen and involvement of a CRNP-PMH and the attending physician, there was no evaluation or explanation recorded for the increased bedtime dose, as confirmed by the DON.
Surveyors found that two residents were administered psychotropic medications without proper documentation, evaluation, or justification. One resident received PRN Lorazepam almost daily over several months without a 14-day limitation or ongoing assessment, while another was prescribed Rexulti for behavioral symptoms that were not documented in their records. Staff interviews confirmed the lack of observed or recorded behaviors to support the medication orders.
A resident with multiple psychiatric and behavioral diagnoses was administered several psychotropic medications without proper documentation of behavioral and mood monitoring, as required by their care plan. Staff were unable to provide the necessary monitoring records, and a pharmacy consultant's recommendation for a gradual dose reduction of one medication was not addressed. This resulted in a deficiency related to the justification and monitoring of psychotropic medication use.
A resident receiving multiple psychotropic medications, including an antidepressant, anxiolytic, and antipsychotic, did not have required side effect monitoring orders or documentation in place. Facility staff confirmed that monitoring should have been implemented during admission or with medication changes, but it was missed and not reflected in the medical record.
A resident received multiple doses of PRN Ativan without documentation of attempted non-pharmacological interventions or adequate behavioral indications for use. Nursing staff did not record required information in the eMAR or other available documentation systems, despite clear expectations for such documentation.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account