Failure to Monitor Antipsychotic Medication Effects: The facility failed to monitor a resident for adverse effects related to antipsychotic use. A cognitively intact resident was receiving Rexulti for dementia-related diagnoses, but the MAR had no monitoring orders and the CCP had no plan for antipsychotic monitoring. The DON confirmed the required monitoring was not completed as required by facility policy.
The facility failed to identify and monitor resident-specific target behaviors for two residents receiving psychotropic meds, failed to monitor for EPS/tardive dyskinesia with antipsychotic use, and used an inappropriate diagnosis for risperidone in one resident. One resident had intact cognition with depression, anxiety, hemiplegia, and seizure disorder, while the other had moderate cognitive impairment with dementia and depression; records and the DON confirmed that the CCP, orders, MAR, and EMR did not include resident-specific behavior monitoring or EPS assessments.
Missing End Date for PRN Psychotropic Medication: A resident with COPD, DM2, schizophrenia, bipolar disorder, depression, and anxiety had a PRN clonazepam order for anxiety with no end date. The pharmacist noted PRN psychotropic meds should have a stop date unless the provider documents a clinical rationale and new duration, and the ADON confirmed the MAR/record lacked an end date.
Psychotropic medication monitoring deficiencies were identified for multiple residents. One resident with bipolar disorder, MDD with psychotic symptoms, and GAD received Seroquel and sertraline, but the EMR, MAR, and TAR did not show specific target behaviors or side effect monitoring despite behavioral concerns being listed in the care plan. Another resident with schizoaffective disorder, bipolar type, received multiple psychotropic medications, but no target behaviors were documented, and the DON confirmed this. The report also noted missing AIMS testing for one resident and lack of sleep pattern monitoring for hypnotic use in three residents.
A resident with dementia, Parkinson’s disease, depression, and a history of myocardial infarction had a PRN order for Zyprexa 5 mg every 6 hours for agitation related to dementia that lacked a 14-day limit or specified duration, as required by facility policy. Record review showed no practitioner documentation of review or renewal of this PRN antipsychotic order, and the DON and interim DON confirmed the absence of an end date and physician notes addressing continuation of the medication.
A resident with CHF, delirium, depression, anxiety, and hospice services had PRN Lorazepam continued beyond the 14-day limit without a clear documented rationale on the pharmacist recommendation. The MAR and progress notes showed PRN doses were given for anxiety, but no behaviors or non-pharmacological interventions were documented, and the DON confirmed the rationale was anxiety.
The facility did not attempt or document required Gradual Dose Reductions (GDRs) for antipsychotic medications in two residents with dementia and behavioral disturbances, and allowed as-needed Haldol to be administered to another resident beyond the 14-day limit without proper evaluation. These actions were not in accordance with facility policy or federal regulations regarding psychotropic medication use.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to medication management.
A resident was administered psychotropic medications without clear medical necessity or was given medications that restricted their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
The facility did not provide required clinical documentation when declining to reduce psychotropic medication doses for two residents, despite recommendations from the consultant pharmacist. One resident with dementia and behavioral symptoms continued on Seroquel and Paroxetine without documented rationale for not attempting a dose reduction, and another resident with sleep disturbances remained on Trazadone without clinical justification for not reducing the dose. Nursing staff confirmed the lack of timely response and documentation.
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