Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Unnecessary psychotropic medication management failures were identified for multiple residents. A resident had a PRN lorazepam order without the required stop date or documented GDR support, another resident’s psychoactive review omitted scheduled and PRN antipsychotics, and lab monitoring for antipsychotic use was not documented for another resident. A fourth resident had PRN lorazepam for dental procedures without an end date, and staff interviews confirmed missing documentation for PRN duration, GDRs, and monitoring.
A resident receiving olanzapine had ordered orthostatic BP monitoring in the lying, sitting, and standing positions, but the measurements were not completed for several months. The resident had no cognitive impairment or psychosis noted on the MDS, and pharmacy reviews did not address the missed monitoring. The DON stated monthly orthostatic BP checks were expected, while the pharmacist said she reviewed the order but did not routinely verify completion.
Several residents with psychiatric diagnoses were administered PRN psychotropic medications without documentation of nonpharmacological interventions being attempted beforehand, despite facility policy and physician orders requiring such actions. Nursing staff and leadership confirmed that these interventions should have been offered and documented, but medical records lacked evidence of compliance.
A resident with significant mental impairment and depression was administered Depakote as a mood stabilizer without documented informed consent. Staff did not obtain consent prior to the first dose because they considered the medication an anti-seizure drug, not recognizing its use as a psychotropic medication required consent. Facility policy required informed consent for psychotropic medications, but this was not followed.
A resident with ALS, major depressive disorder, and ventilator dependence was prescribed clonazepam for anxiety, but staff did not identify or monitor target behaviors related to the medication. Nursing staff and the DON confirmed that there was no ongoing documentation of anxiety behaviors, despite facility policy requiring such monitoring for psychotropic medication use.
Two residents receiving PRN antianxiety medications were not assessed by a physician for continued need, with no documentation of rationale, frequency, or effectiveness of use. Pharmacy reviews did not identify the lack of reassessment, and nursing staff confirmed that required 14-day reviews were not completed. No facility policy on PRN psychotropic medication reassessment was provided.
A resident prescribed Olanzapine and other psychotropic medications, with a high fall risk and an order for monthly orthostatic blood pressure monitoring, did not have these checks completed or documented for two months. Staff interviews confirmed the monitoring was not performed, despite facility policy requiring side effect monitoring for antipsychotic use.
The facility did not ensure that psychotropic medications were prescribed with clearly identified target behaviors or symptoms, nor did staff monitor for these behaviors to assess medication effectiveness. For example, a resident with depression and anxiety received antipsychotic medications without individualized target behaviors documented in the care plan or medical record. Staff, including CNAs, LPNs, and RNs, were unable to identify specific behaviors to monitor, and the facility's policy requiring such documentation was not followed for several residents.
The facility did not complete required monitoring for side effects of antipsychotic medications, such as AIMS assessments and orthostatic blood pressure checks, for several residents with significant cognitive and psychiatric conditions. Additionally, PRN psychotropic medication orders for multiple residents lacked required stop dates and were not limited to 14 days as per facility policy, with no documented physician evaluation for continued use. These deficiencies were confirmed through record review and staff interviews.
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