Unauthorized Administration of Chemical Restraint
Summary
The facility failed to ensure that a resident was free from chemical restraints, as staff administered an injectable anti-psychotic medication, Chlorpromazine, twice within an 8-hour period without the resident's consent and without a physician's order. The resident, who had a history of Parkinsonism, Paranoid Schizophrenia, and other mental health disorders, was given the medication by an LPN without verifying the current medication orders. The medication had been discontinued in September 2023, and there was no valid order for its administration at the time of the incident. The LPN administered the first injection at 10:30 PM after the resident exhibited behaviors such as spitting and verbal aggression. The LPN did not inform the resident about the injection, and the resident expressed that the action was sneaky. A second injection was reportedly given at 5:30 AM, although this was not witnessed by the CNA who was monitoring the resident. The LPN admitted to not checking the medication orders or documenting the administration of the medication in the Medication Administration Record (MAR). As a result of the unauthorized administration of Chlorpromazine, the resident was sent to the emergency room with symptoms of lethargy, facial swelling, and a possible allergic reaction. The emergency room physician was not initially aware of the Chlorpromazine injections, which could have posed additional risks to the resident's health. The facility's failure to follow proper medication administration protocols and to attempt less restrictive alternatives before resorting to chemical restraints led to this deficiency.
Removal Plan
- Facility Restraint Policy was reviewed by Regional Director of Operations and was found to be in compliance with state and federal regulations.
- Facility Administrator initiated in-servicing, for all staff, on the use of non-pharmacological interventions for resident behaviors all other staff will be in-serviced before the beginning of the next shift.
- The Administrator will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand using non-pharmacological interventions for resident behaviors.
- Director of Nursing in-serviced all nurses to obtain orders for the administration of an injectable anti-psychotic to be completed by the beginning of the next scheduled shift.
- Director of Nursing in-serviced all nurses on documenting all medication administration in the MAR to be completed by the beginning of the next scheduled shift.
- Social Service Director will interview 3 residents, 3 times weekly x4 weeks to ensure that residents are getting their medication as prescribed.
- IDT has assessed R1 and care plan updated to reflect non-pharmacological interventions for behaviors.
- IDT team reviewed all residents for the potential to not be free of abuse and care plans updated to reflect interventions to protect residents from abuse.
- IDT in-serviced by Regional Director of Operations to review any resident for changes in behaviors, increase in behaviors or new behaviors in order to investigate and identify any potential triggers prior to an incident, ensure that person centered interventions are developed to alleviate/decrease behaviors and to communicate identified triggers and interventions to staff.
- Residents who trigger during this IDT review will be discussed during morning meeting and a root cause analysis will be completed to determine potential triggers. Individualized intervention will be developed to decrease episodes of behaviors, in order to prevent situations that may cause abuse to a resident.
- The nurses in question were suspended pending investigation of the med error and ultimately terminated.
- ADON completed an audit of the medication carts and medication room to ensure there were no medications present that did not have orders from the physician.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
A resident with Alzheimer’s disease, severe cognitive impairment, depression, anxiety, delusions, and behavioral symptoms was receiving lorazepam both as a scheduled dose and PRN every four hours for restlessness and agitation, including a topical form if oral medication was refused. Physician orders for the PRN lorazepam lacked stop dates, and although the consultant pharmacist recommended a stop date or GDR, the physician declined, citing hospice and palliative care without specifying a duration. The nurse overseeing psychotropic use confirmed the absence of a stop date and uncertainty about requirements for palliative residents, despite facility policy mandating that PRN psychotropic medications (other than antipsychotics) be limited to 14 days unless a longer timeframe is explicitly ordered. This resulted in a deficiency related to unnecessary psychotropic medication management.
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.
A resident with dementia, bipolar disorder, anxiety disorder, epilepsy, chronic pain, and prior stroke had a PRN Seroquel 25 mg order for agitation related to anxiety that remained active well beyond the 14-day limit set by facility policy for PRN psychotropic medications. The MAR showed multiple PRN administrations, and observations later noted the resident in a wheelchair with eyes closed, chin on chest, and tongue hanging out. Nursing staff could not locate any documentation that the attending physician or a mental health provider had re-evaluated and documented the continued need for the PRN antipsychotic, and the MD was unsure about the 14-day documentation requirement. The pharmacist reported she had recommended discontinuation of the PRN Seroquel during a medication regimen review. This constituted a failure to prevent potential chemical restraint by not ensuring timely re-evaluation and documentation for continued PRN antipsychotic use.
Surveyors found that a resident with dementia and depression received multiple PRN doses of Lorazepam for anxiety/agitation over several months without any documented evidence that non-pharmacological interventions were attempted beforehand, despite a facility policy requiring such measures for residents on psychotropic drugs. The Nursing Home Administrator confirmed that documentation of these interventions was absent and should have been present.
A resident with dementia, anxiety, depression, and Alzheimer’s disease received multiple PRN and routine Ativan orders with inconsistent and clinically questionable indications, such as nausea related to depression and comfort related to Alzheimer’s. The MAR showed repeated PRN Ativan administrations with progress notes documenting symptoms or reasons for use on only a small fraction of doses, while nursing staff stated they did not believe separate notes were necessary and could not recall the resident’s symptoms at the time of administration. A pharmacy review form requesting action on the PRN psychotropic order, including compliance with the 14‑day CMS guideline and documentation of indication and duration, was left entirely incomplete by the prescriber. Family members reported that Ativan had previously caused an opposite, aggressive reaction at home, stated they had stopped it before admission, and said they repeatedly requested that it not be given, yet Ativan was reordered and administered several times, and they were not informed when it was discontinued and restarted. Staff, including an RN and an LPN, reported that the resident became more aggressive and violent after receiving Ativan, but the facility did not ensure appropriate review, documentation, or response to these concerns.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Implement Required Stop Orders for PRN Antianxiety Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving PRN antianxiety medication had appropriate stop orders in place, as required by facility policy. The resident had diagnoses including late-onset Alzheimer’s disease, pain, anxiety, severe cognitive impairment, delusions, and behavioral symptoms such as paranoia and agitation. The resident’s admission MDS documented severe cognitive impairment and behavioral symptoms, and the Behavioral Symptom CAA noted multiple episodes of paranoia and agitation, leading to an increased dose of Seroquel and lorazepam 1 mg PRN every four hours for anxiety. The care plan documented severely impaired cognition, depression, and use of antidepressant and antipsychotic medications for anxiety and paranoid thoughts, with interventions such as redirection and monitoring for worsening depression. Physician orders dated 01/30/26 and 03/27/26 directed staff to administer lorazepam 1 mg every four hours PRN for restlessness/agitation and topical lorazepam 2 mg/ml every four hours PRN if the oral dose was refused, both without stop dates. Another order dated 02/19/26 directed scheduled lorazepam 1 mg in the afternoon for anxiety disorder. The consultant pharmacist’s review on 02/09/26 recommended a stop date or GDR for the anxiolytic, but the physician declined, stating the resident was on hospice and receiving palliative care, without specifying a duration for continued PRN use. The administrative nurse responsible for monitoring psychotropic use confirmed that the physician had declined a stop date and was unsure about the need for a stop order for palliative residents. This was inconsistent with the facility’s Unnecessary Drugs and Psychotropic Drugs policy, which required limiting PRN psychotropic medications (other than antipsychotics) to 14 days unless a longer timeframe was deemed appropriate by the prescriber, thereby resulting in the cited deficiency.
Failure to Document Indications and Monitoring for Psychotropic Medications
Penalty
Summary
Surveyors found that the facility failed to ensure a resident’s psychotropic medication regimen was free from potentially unnecessary medications and lacked adequate indications for use. Facility policy dated 8/15/25 required that all residents receiving psychoactive medications have their behaviors, the effectiveness of pharmacological and non-pharmacological interventions, and the potential for gradual dose reduction monitored and documented. One resident, admitted on 3/27/2026 with diagnoses including paraplegia, depression, anxiety disorder, and bipolar disorder, had physician orders for multiple psychotropic medications: buspirone 10 mg (2 tablets three times daily), escitalopram 20 mg once daily, mirtazapine 15 mg at bedtime, and quetiapine 100 mg at bedtime plus quetiapine 25 mg once daily. The clinical record did not contain specific diagnoses linked to the use of each of these medications. Review of the resident’s clinical record also showed no documented non-pharmacological interventions, no documentation of the effectiveness of the prescribed psychotropic medications, and no evidence of monitoring for side effects or behaviors related to psychotropic use. During interviews, the RN Assessment Coordinator confirmed that the psychotropic medication orders lacked diagnoses for usage and that the record did not include documentation of interventions, medication effectiveness, or monitoring of side effects and behaviors. The Administrator and DON likewise confirmed that the facility failed to ensure the resident’s medication regimen was free from potentially unnecessary psychotropic medications without adequate indications for use, as required by state regulations and facility policy.
Failure to Re-Evaluate PRN Antipsychotic Order Within Required 14-Day Limit
Penalty
Summary
The deficiency involves the facility’s failure to comply with requirements for PRN antipsychotic medications, resulting in a chemical restraint concern for one resident. The resident, an older adult with dementia, epilepsy, chronic pain, bipolar disorder, anxiety disorder, and a history of cerebral infarction, had a physician order for Seroquel 25 mg to be given by mouth three times a day as needed for agitation related to anxiety disorder, starting on 2/3/26. The February MAR showed that the PRN Seroquel was administered on three occasions (2/11/26, 2/14/26, and 2/22/26). Observations on 3/12/26 documented the resident in a wheelchair in the lobby with eyes closed, chin resting on the chest, and later with the tongue hanging out of the mouth, while a musician performed nearby. Record review and staff interviews revealed that the PRN Seroquel order remained active from 2/3/26 through at least 3/26/26 without documented re-evaluation by the physician or a mental health provider, despite facility policy limiting PRN psychotropic orders to 14 days and requiring an evaluation and documentation to renew PRN antipsychotic orders. A nurse stated that the physician re-evaluated PRN antipsychotics during quarterly gradual dose reductions and monthly order recapitulations, but could not identify any documentation of a specific re-evaluation or rationale for continuing this PRN Seroquel order. The medical director could not recall if he documented a re-evaluation and appeared unaware that documentation every 14 days was required to continue a PRN antipsychotic. The facility’s pharmacist reported that, during a recent medication regimen review, she noted the PRN Seroquel order and recommended its discontinuation. This failure resulted in the resident having the potential to receive an antipsychotic dose beyond the 14-day limit without the required re-evaluation.
Lack of Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s psychotropic medication regimen was free from unnecessary medication use and that non-pharmacological interventions were implemented as required by facility policy. The facility’s policy on psychotropic medications, dated February 12, 2026, stated that residents using psychotropic drugs should also receive non-pharmacological interventions to facilitate reduction or discontinuation of these drugs. Resident 42’s quarterly MDS assessment dated March 12, 2026, documented that the resident was cognitively intact, required staff assistance for daily care needs, and had diagnoses including dementia and depression. Physician orders for Resident 42 between early January and mid-March 2026 directed administration of 0.50 mg Lorazepam every eight hours as needed for anxiety/agitation for 14-day periods. The MARs for January, February, and March 2026 showed multiple administrations of 0.50 mg Lorazepam on specific dates and times across those months. However, there was no documented evidence that non-pharmacological interventions were attempted prior to administering Lorazepam on any of those occasions. In an interview on March 25, 2026, the Nursing Home Administrator confirmed that there was no documentation of non-pharmacological interventions before the PRN Lorazepam doses and acknowledged that such documentation should have been present.
Failure to Manage and Document PRN Psychotropic (Ativan) Use and Respond to Family Concerns
Penalty
Summary
The deficiency involves the facility’s failure to appropriately manage and document the use of the psychotropic medication Ativan for one resident with dementia, anxiety, depression, and Alzheimer’s disease. The resident’s diagnoses included unspecified dementia with agitation, generalized anxiety disorder, Alzheimer’s disease, and depression. The resident’s care plan identified multiple behavior-related focus areas, including anxiousness, restlessness, destructiveness, potential physical aggression, delusional thinking, hallucinations, delirium, and acute confusion, with interventions that included administering psychotropic medications as ordered and monitoring for effects and effectiveness every shift. The Minimum Data Set documented that the resident was not cognitively intact, had frequent depressive symptoms, and exhibited behaviors such as hitting, scratching self, pacing, rummaging, public sexual acts, and public disrobing, and that the resident was on high-risk drug classes including an antipsychotic and an antidepressant. The facility’s records showed multiple Ativan orders with inconsistent and clinically questionable indications and inadequate documentation. An initial PRN Ativan order for 0.5 mg every 12 hours was entered with an indication of nausea related to depression, followed by a second PRN order for the same dose every 12 hours for comfort related to Alzheimer’s disease, and later a routine order every 12 hours for anxiety, aggression, and agitation related to generalized anxiety disorder. The nurse practitioner later stated that the first indication (nausea related to depression) was something she had only seen in hospice and not related to depression, and that neither the first nor second indication (comfort related to Alzheimer’s) was appropriate. The February MAR showed that the resident received PRN Ativan multiple times under these orders, but progress notes documented the symptoms or reasons for administration on only 1 of 7 PRN doses under the first order and 1 of 4 PRN doses under the second order. Nursing staff, including the DON and an LPN, stated they did not believe it was necessary to write a progress note each time a PRN medication was administered and believed the diagnosis on the MAR was sufficient, and one LPN could not recall the resident’s symptoms at the time she administered Ativan. The facility also failed to respond appropriately to a pharmacy review and to family concerns regarding Ativan use. A pharmacist’s medication review form for the PRN Ativan order requested that the prescriber choose among options to discontinue, add a stop date per CMS 14-day PRN psychotropic guidelines, or extend the order with a specified duration, indication, and rationale. None of these options were selected, and the prescriber response section was left blank, with no indication that the prescriber acknowledged or signed the review. The administrator acknowledged that PRN psychotropic medications should be reviewed within 14 days and either reordered or discontinued and was unsure why this review was missed. The resident’s power of attorney and another family member reported that Ativan had previously caused an idiosyncratic, opposite reaction at home, that they had stopped it before admission, and that they requested on multiple occasions that Ativan not be administered. They stated they were not informed when Ativan was discontinued and then reordered, and one family member denied giving verbal consent for Ativan use. Nursing staff, including an RN and an LPN, reported that each time the resident received Ativan he became more aggressive, violent, and agitated, and one RN stated she had voiced concerns to the DON. Despite these reports and the family’s requests, Ativan was reordered and administered multiple times, with inadequate documentation of indications and without clear evidence of prescriber review or acknowledgment of the pharmacist’s recommendations.
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