A resident with severe cognitive impairment, dysphagia, and NPO status exhibited frequent behaviors including yelling out, repeatedly requesting water, drinking from inappropriate sources, pulling out a G‑tube, and removing O2. The care plan identified behavioral problems related to unsafe drinking but contained only generic statements and no specific, individualized interventions. Nursing staff and the SSD reported daily behaviors and limited interventions beyond checking on the resident, while the family stated they were not asked for input on non‑pharmacologic strategies and had expressed a desire to avoid sedation. Despite a facility policy requiring thorough assessment and trial of person‑centered non‑drug approaches before psychotropic use, the resident was maintained on Seroquel for behavior and later started on clonazepam, which was then increased for restlessness, anxiety, and behavioral issues without documented comprehensive assessment or clear evidence that individualized non‑pharmacologic interventions had been implemented and evaluated first.
Unclear indication and rationale for duplicate antipsychotic therapy. A resident with dementia, anxiety, adjustment disorder, psychotic disorder with delusions, and insomnia was prescribed two antipsychotics: paliperidone ER daily and quetiapine BID. Review of MH provider notes found no documented clinical rationale for the dual therapy, and the SW stated the chart did not explicitly address why both medications were being used.
A resident with dementia with psychotic disturbance and hospice services was started on PRN Ativan for anxiety/restlessness after hospice input, with non-pharmacologic interventions documented before administration. The PRN order was later extended to 90 days, but the record lacked documentation supporting use beyond the initial 14-day period; staff later gave additional doses for wandering/restlessness, and an NP reported re-evaluations of the medication.
Unjustified Increase in Antipsychotic Medication: A resident with anxiety disorder, delusional disorders, and vascular dementia received an increased Seroquel dose despite no recent documented behaviors, hallucinations, or delusions in the chart. Psychiatry noted the resident had been stable, but hospice and nursing notes later referenced yelling out and anxiety at lunch, leading to an added afternoon Seroquel dose on top of the existing BID order. Staff interviews confirmed behavior documentation was limited.
A resident with mental health diagnoses was prescribed PRN hydroxyzine for anxiety without a 14-day stop date, and no provider rationale was documented to justify use beyond this period. The DON confirmed that the required stop dates were not in place for the medication orders.
A resident with severe cognitive impairment and dementia was prescribed Haldol and Olanzapine without a proper psychiatric diagnosis or adequate documentation. Staff administered these psychotropic medications without consistently attempting non-pharmacological interventions or monitoring for side effects, leading to increased sedation, weight loss, falls, and decreased ability to communicate. The resident's guardian was not properly informed of medication changes, and care plans lacked necessary details, resulting in significant harm including dehydration and hospitalization.
A resident with Alzheimer's dementia and a history of falls was prescribed lorazepam without adequate indication, monitoring, or consent. After starting the medication, the resident experienced multiple falls, culminating in a severe fall that caused pelvic fractures and death. The facility did not review the medication's role in the falls, failed to monitor for adverse effects, and did not obtain required consent, leading to significant harm.
A resident with multiple diagnoses, including anxiety and dementia, had a PRN Ativan order that lacked a specified stop-date despite repeated pharmacist recommendations and physician indications for a limited duration. The order remained unchanged in the system, and the facility's policy did not address updating orders based on these recommendations.
A resident with severe cognitive impairment was prescribed PRN alprazolam for anxiety, but the physician did not document the clinical rationale or duration of use in the medical record as required. Despite a pharmacist's request and facility policy mandating such documentation for PRN psychotropic medications, the necessary information was not provided.
Two residents receiving antipsychotic medications were not appropriately monitored for orthostatic hypotension, despite physician orders requiring such monitoring. Review of medical records showed no documentation of orthostatic blood pressure readings for either resident, and the DON confirmed that this monitoring and documentation was expected.
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