Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
A resident with anxiety and dementia had a PRN lorazepam order written without a specified stop date, allowing administration every two hours as needed for anxiety. Staff administered the medication multiple times over two months, and there was no documented evidence that a physician re-evaluated the PRN psychotropic order after 14 days. The DON confirmed that the order lacked an end date, resulting in a failure to prevent potential chemical restraint related to psychotropic medication use.
The facility failed to ensure PRN psychotropic medication regimens were supported by adequate documentation for three residents. One resident with anxiety and altered mental status received PRN Vistaril and Zyprexa, and two residents with diagnoses including dementia, anxiety, lung cancer, and respiratory failure received repeated PRN Ativan doses. In each case, the record lacked documentation of non-pharmacological interventions before administration, and two Ativan orders also lacked a 14-day stop date and documented rationale for continued use; the DON confirmed the missing documentation.
A resident with metabolic encephalopathy and severe cognitive impairment received PRN lorazepam for terminal agitation, but the order lacked a documented clinical rationale and duration to support use beyond the 14-day limit. The eMAR also did not show that non-pharmacological interventions were attempted before administration, and the record did not document agitation at the time the medication was given; the DON confirmed the missing documentation.
PRN psychotropic meds were used without the required 14-day stop date or documented clinical rationale for continued use, and the records did not show non-pharmacological interventions were tried before administration. One resident with a pulmonary nodule, pain, and a retroperitoneal hematoma received repeated PRN lorazepam and one PRN haloperidol dose, while another resident with COPD, A-fib, and HTN received daily PRN lorazepam. The DON confirmed the missing documentation.
A resident who was cognitively intact and had anxiety received PRN Lorazepam repeatedly over an extended period. The MAR showed multiple administrations of the antianxiety medication, but there was no documented physician rationale to extend the PRN psychotropic order beyond the 14-day limit required by facility policy.
The facility failed to ensure a resident’s psychotropic regimen was free from unnecessary medication and did not have informed consent before starting aripiprazole for confusion. The resident was cognitively impaired, needed help with daily care, and had diagnoses including anxiety and depression. The DON confirmed the lack of informed consent for the antipsychotic.
A resident with Alzheimer’s disease and dementia, identified as high risk for elopement, had a PRN quetiapine order for agitation in addition to other psychotropic and dementia-related medications. The care plan included interventions such as reorientation, frequent monitoring, diversionary activities, and redirection, and documentation showed that redirection and contacting the resident’s husband were sometimes effective in calming exit-seeking and agitation. However, PRN quetiapine was administered multiple times without consistent documentation of the specific behaviors present, without evidence that non-pharmacological interventions were attempted and found ineffective before administration for half of the doses reviewed, and without clearly defined, measurable behavioral parameters to guide staff on when PRN antipsychotic use was clinically indicated, resulting in the use of a chemical restraint contrary to facility policy.
Unaddressed MRRs for Psychotropic and Antidepressant Medications: The facility failed to ensure monthly MRRs were completed and reviewed by the attending physician for three residents receiving psychotropic or antidepressant medications. Records showed missing physician responses to pharmacist recommendations involving Zyprexa, Remeron, Seroquel, and Effexor, while CRNPs documented decisions such as no GDR or contraindication to GDR. The residents had diagnoses including psychotic disorders, dementia with agitation, stroke, anxiety, hypertension, repeated falls, and depression.
Surveyors determined that the facility did not follow its psychoactive medication policy for a resident receiving multiple psychotropic drugs, including buspirone, escitalopram, mirtazapine, and quetiapine. The resident’s record, despite diagnoses such as paraplegia, depression, anxiety disorder, and bipolar disorder, lacked specific diagnoses tied to each psychotropic medication, contained no documentation of non-pharmacological interventions, and did not show monitoring of medication effectiveness, behaviors, or side effects. The RNAC, Administrator, and DON acknowledged that the required indications and monitoring for these psychotropic medications were not documented.
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