A resident with depression, anxiety, and hospice services received PRN lorazepam without an end date on the order, and the PRN use continued beyond 14 days without documented physician rationale. The resident’s care plan called for review of PRN anti-anxiety medication by day 14, but the MAR showed repeated use over multiple days, and staff documented ongoing anxiety and a later scheduled anxiolytic order.
A resident with a hip fracture received PRN lorazepam for agitation and anxiety over several months, with administration records showing repeated use beyond the facility's 14-day policy limit. Staff confirmed that a physician did not re-evaluate or document a rationale for extending the PRN order as required.
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 with dementia and depression received PRN psychotropic medications without physician evaluation or documented rationale for use beyond 14 days. Staff were unaware of the 14-day limitation, resulting in the continuation of these medications past the required timeframe without proper review.
A resident with dementia was prescribed multiple psychoactive medications, including an antipsychotic, despite showing increasing side effects as measured by AIMS scores. Staff and leadership acknowledged that the antipsychotic was used to address calling out behaviors that were not distressing to the resident, and no comprehensive assessment or gradual dose reduction was performed, with the facility relying on pharmacist reviews instead of their own evaluations.
A resident with a history of spinal abscess and paralysis had a PRN order for Prochlorperazine that was not reviewed or evaluated by a physician within the required 14-day period. An LPN confirmed that the order continued beyond the allowed timeframe without the necessary assessment or rationale from the prescriber.
A resident with PTSD and insomnia continued to receive Ambien nightly despite a psychologist's recommendation to transition to an alternative sleep aid. The resident was open to the change, but staff did not follow up on the recommendation, and the regional nurse later confirmed the medication had not been discontinued as directed.
A resident with a history of anxiety, hallucinations, and disorientation was repeatedly administered haloperidol without documented indications or behaviors warranting its use. Multiple LPNs gave the antipsychotic for reasons such as agitation or difficulty sleeping, but failed to record specific symptoms, non-pharmacological interventions, or the effectiveness of the medication, resulting in the use of unnecessary psychotropic medication as a chemical restraint.
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