Psychotropic medication monitoring and documentation were incomplete for several residents. One resident received quetiapine without a documented indication or diagnosis, another received Seroquel without orthostatic BP monitoring, and two residents on routine antipsychotics did not have timely AIMS assessments. Staff confirmed the missing diagnosis, BP checks, and AIMS timing did not meet expectations.
Failure to document a resident-specific rationale for declining a psychotropic GDR. A resident with cognitive impairment, anxiety, depression, and insomnia had long-term citalopram use and lorazepam for anxiety-related behaviors. Pharmacy recommended a citalopram GDR, but the provider left the required rationale blank, and the IDT note cited maladaptive behaviors without identifying them or linking them to citalopram. The record also did not show a failed GDR of citalopram.
Psychotropic medication monitoring and documentation were deficient for three residents. A resident with anxiety received clonazepam without documented ASE monitoring, a cognitively impaired resident received PRN Seroquel without an AIMS test and PRN lorazepam without a 14-day stop date, and another resident with anxiety received repeated higher-dose PRN lorazepam without documentation of the behaviors supporting the dose given. Staff acknowledged missing monitoring and documentation in the records.
Unnecessary Antipsychotic Use for Resident with Dementia and Behaviors: A resident with dementia, depression, and severe cognitive impairment was given Seroquel for behaviors including yelling, screaming, hitting, grabbing, and increased confusion. The record lacked information about pre-admission behaviors and did not include personalized monitoring for psychosis, while staff noted the resident came from an ALF, believed they worked at the facility, and had also been found to have a UTI.
Psychotropic meds were not regularly monitored or documented with specific target behaviors for several residents. Records showed generic behavior monitors, care plans that did not link meds to the behaviors they were intended to treat, missing documentation of non-pharmacological interventions before PRN alprazolam, and inconsistent nursing/CNA charting for residents receiving antipsychotic and antidepressant medications.
Psychotropic meds were not properly monitored or justified for three residents. One resident with dementia and depression had quetiapine and trazodone ordered, but there was no target behavior monitoring for the antidepressant. Another resident had escitalopram and PRN lorazepam for anxiety despite no MH dx listed in the facility record, and the DNS said the diagnosis and justification should have been documented. A third resident with Alzheimer’s, anxiety, and physical aggression received PRN risperidone, lorazepam, and haloperidol for agitation or care-related behaviors, but the TARs did not document the behaviors or non-drug interventions attempted before the meds were given, and the resident also showed oral-facial movements consistent with tardive dyskinesia that were not documented on the TAR.
PRN psychotropic meds were not properly limited to 14 days or supported by documented rationale for extended use, and non-pharmacological interventions were not consistently documented for two residents. One resident had PRN Prochlorperazine ordered for nausea/vomiting with no timely non-pharm documentation and repeated administrations, while another resident had PRN Ativan ordered without an end date and used over several months for comfort, agitation, sleep, and other symptoms without the required justification.
The facility did not provide or document nonpharmacological interventions before administering psychotropic medications to three residents with depression, anxiety, or mood disorders. Additionally, staff failed to complete required AIMS assessments and did not monitor for adverse side effects or target behaviors in a resident receiving antipsychotic and antidepressant medications, contrary to facility policy.
A resident with severe cognitive impairment and diagnoses including dementia with agitation and delirium was prescribed Olanzapine, an antipsychotic medication. Facility policy required an AIMS test to be completed upon admission and when starting antipsychotic therapy, but staff interviews and record review confirmed that this assessment was not performed or documented.
Three residents received psychotropic medications without required monitoring for target behaviors, nonpharmacological interventions, or documented consent. Staff did not document behavior monitoring or obtain consent for antianxiety medication, and care plans lacked nonpharmacological approaches, as confirmed by nurse supervisors.
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