Inappropriate Use of Psychotropic Medication as Chemical Restraint
Summary
The facility failed to prevent the use of unnecessary psychotropic medications, resulting in the over-sedation and decline in physical functioning of a resident, identified as R12. R12 was admitted with diagnoses including conversion disorder with seizures, generalized anxiety, and unspecified dementia with behavioral disturbances. Initially, R12 was prescribed Risperdal 2 mg orally for unspecified dementia with behavioral disturbances. However, after an increase in aggressive behaviors and a subsequent psychiatric hospitalization, the medication was changed to Risperidone 125 mg administered subcutaneously once a month. Observations and interviews revealed that R12 exhibited behaviors such as agitation, cursing staff, restlessness, and hallucinations. Despite these behaviors, R12's Minimum Data Set (MDS) assessments documented no physical or verbal behavioral symptoms directed towards others, and no rejection of care. The facility's social services and nursing staff confirmed that R12's behaviors included false allegations and yelling during care, but there was no evidence of self-harm or aggression towards other residents. The change in medication form was due to R12's refusal to take the oral medication. The administration of the antipsychotic injection led to R12 experiencing significant sedation, as noted in nurse's notes and staff interviews. R12 was observed to sleep for extended periods post-injection, which contributed to a decline in her physical condition and ability to perform activities of daily living. The facility's failure to appropriately monitor and adjust the use of psychotropic medication for R12, in accordance with their own procedures, resulted in the use of a chemical restraint that was not required to treat medical symptoms or behavior manifestations of mental illness.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia and intact cognition was given a one-time dose of Haldol by an LPN after an attempt to hit staff during a dressing change, despite no documented behaviors or justification in the medical record. Facility policy required antipsychotic use only for specific conditions and after other interventions, but there was no evidence of imminent danger or proper documentation to support the administration.
Two residents were administered psychotropic medications without appropriate diagnoses or proper justification for not attempting gradual dose reductions. One resident received an antipsychotic for anxiety without a documented psychiatric diagnosis, while another continued on multiple psychotropic drugs despite pharmacy recommendations for dose reduction, with provider denials lacking clear clinical contraindication.
A resident with dementia and Parkinson's disease was given Seroquel without a documented or appropriate diagnosis to support its use. The medication was ordered and administered for anxiety and hallucinations, despite the absence of documented behaviors or psychiatric disorders and without adherence to FDA-approved indications. Facility staff, including the NP and DON, confirmed the lack of proper documentation and awareness of policy requirements.
A resident with severe cognitive impairment and multiple diagnoses received PRN Ativan gel for agitation and anxiety without a required 14-day stop date. The medication was administered repeatedly over several months, contrary to facility policy and regulations, as confirmed by interviews with clinical leadership.
The facility did not ensure that prn orders for psychotropic medications, including anti-psychotics and anti-anxiety drugs, were limited to 14 days and only extended with proper face-to-face evaluations and clinical rationales. Two residents received prn medications for extended periods without required end dates or documentation of non-pharmacological interventions prior to administration, contrary to facility policy and federal regulations.
A resident was prescribed antipsychotic medication for depression despite having no documented diagnosis of depression or related care plan in the medical record. The MDS assessment indicated the resident was cognitively intact and showed no symptoms of depression, and facility policy requires psychoactive medication orders to be supported by clinical diagnoses or behavioral symptoms.
Failure to Prevent Unnecessary Use of Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cerebral infarction, glaucoma, anxiety disorder, and vascular dementia was administered an antipsychotic medication (Haldol) without proper documentation or justification. The resident, who had intact cognition and required assistance with transfers, had no routine psychoactive medication orders. After returning from the hospital, the resident exhibited agitation and combative behavior, leading to a one-time order for Haldol and Ativan if needed for agitation and aggression. However, the medications were not administered at that time, and the resident later rested calmly. Over 24 hours later, an LPN administered Haldol to the resident after the resident attempted to hit the nurse during a dressing change. There was no documentation in the progress notes to indicate the reason for administering the medication at that time, and behavior tracking did not show any documented behaviors warranting its use. Facility policy required that antipsychotic medications only be used for specific conditions and after other causes of behavioral symptoms had been addressed. The Acting DON confirmed there was no evidence of imminent danger to self or others to justify the use of Haldol, and the only incident noted was the resident pulling a fire alarm earlier, with no further documentation.
Failure to Ensure Appropriate Use and Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had appropriate diagnoses and that proper justification was provided for not attempting gradual dose reductions. For one resident, olanzapine, an antipsychotic medication, was ordered for anxiety upon admission without a documented psychiatric diagnosis. The DON and ADON confirmed that the medication was continued from the hospital without an appropriate diagnosis, and there was no documentation to justify its use. Facility policy required that the prescribing practitioner and interdisciplinary team determine if continuing such medication was justified when no clear indication was present, but this was not followed. For another resident, multiple psychotropic medications were prescribed, including hydroxyzine, trazodone, and buspirone. Pharmacy recommendations to gradually reduce the dose of hydroxyzine were made on two occasions, but the provider denied these requests, citing reasons such as scheduled surgery and shoulder pain. There was no evidence that further attempts at gradual dose reduction were made, nor was there documentation of clinical contraindication as required by facility policy. The facility's failure to ensure appropriate diagnoses and to attempt or justify not attempting gradual dose reductions for psychotropic medications resulted in noncompliance with their own policies.
Antipsychotic Medication Administered Without Appropriate Diagnosis
Penalty
Summary
A deficiency was identified when a resident was administered Seroquel (quetiapine), an antipsychotic medication, without an appropriate or documented diagnosis to support its use. The resident had diagnoses of Parkinson's disease, dementia without behavioral or mood disturbances, altered mental status, and depression. The care plan noted altered behaviors and hallucinations, but the Minimum Data Set assessment indicated severe cognitive impairment with no behaviors or psychiatric/mood disorders. Despite this, Seroquel was prescribed and administered over several months, with dosage adjustments made for reported anxiety and behaviors, but without any formal diagnosis documented in the medical record. Interviews with facility staff revealed that the Nurse Practitioner ordered Seroquel based on a hospice recommendation, acknowledging it was used off-label and not in accordance with FDA-approved indications. The DON was unaware that the medication order lacked an appropriate diagnosis and did not recognize that the documented reasons for use were not FDA-approved indications. Facility policy required psychotropic medications to be prescribed only with appropriate diagnosis or supporting documentation, which was not followed in this case.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a psychotropic medication, specifically Ativan (Lorazepam) gel, prescribed for a resident with Alzheimer's disease and other significant diagnoses, had a required 14-day stop date. The medication was ordered as an as-needed (PRN) controlled substance for agitation and anxiety, but the order did not include a 14-day limitation as mandated by facility policy and regulations. Despite the absence of a stop date, the medication continued to be administered to the resident on multiple occasions over several months. Record review showed that the medication was given repeatedly after the period it should have been discontinued, with administration dates spanning several months beyond the initial order. Interviews with both the Regional Clinical Support and the Director of Nursing confirmed that the facility did not follow its own policy or regulatory requirements regarding the 14-day stop for PRN psychotropic medications. The facility's policy clearly stated that such orders should not be renewed beyond 14 days without a healthcare practitioner's evaluation, which did not occur in this case.
Failure to Limit PRN Psychotropic Medication Orders and Document Non-Pharmacological Interventions
Penalty
Summary
The facility failed to comply with federal regulations regarding the use of psychotropic medications, specifically by allowing as-needed (prn) orders for anti-psychotic and anti-anxiety medications to extend beyond the required 14-day limit without appropriate face-to-face evaluations and clinical rationales. In one case, a resident with schizo-affective disorder, bipolar disorder, anxiety, depression, and insomnia had a prn order for Zyprexa (an anti-psychotic) to be administered intramuscularly for agitation, with the order set for 180 days. Despite pharmacy recommendations referencing the 14-day regulatory limit and the need for prescriber evaluation, the psychiatrist continued to order the medication for extended periods. The medication was administered 12 times over five months, and in 10 of those instances, there was no documentation that non-pharmacological interventions (NPIs) were attempted prior to administration. Another resident, admitted with diagnoses including a sacrum fracture, stomach cancer, neuropathy, anemia, hypertension, and anxiety, and who was on hospice care, had prn orders for Xanax and lorazepam for anxiety. These orders did not include end dates, failing to specify the duration of use as required by regulation. The DON confirmed that these prn orders lacked the necessary time limitations. The facility's policy stated that prn orders for anti-psychotic medications should be limited to 14 days and not renewed without an in-person evaluation by the prescriber. However, the facility did not adhere to this policy in the cases reviewed, resulting in extended prn orders and a lack of documented attempts at NPIs prior to administering anti-psychotic medications.
Antipsychotic Medication Prescribed Without Supported Diagnosis
Penalty
Summary
The facility failed to ensure that the use of antipsychotic medication for a resident was based on a clinically supported diagnosis. Record review showed that a resident with diagnoses including bipolar disorder, psychoactive substance abuse, and nicotine dependence was prescribed Venlafaxine HCL for depression and Quetiapine Fumarate for depression. However, the admission MDS assessment indicated the resident was cognitively intact and had no symptoms of depression. Further, there was no current diagnosis of depression documented in the medical record, nor was there a care plan related to depression. The facility's own policy requires that psychoactive medication orders be supported by appropriate clinical diagnoses or behavioral symptoms, which was not followed in this case.
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