Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Summary
The facility failed to ensure that as needed (PRN) orders for psychotropic drugs were limited to 14 days, as required by regulations. Specifically, for one resident, an as needed antianxiety medication, Ativan, was ordered for periods longer than 14 days without documented physician rationale to extend the duration of the order. The facility's policy on psychotropic medication use mandates that such medications are not prescribed on an as needed basis unless necessary for a diagnosed condition, and any extension beyond 14 days must be justified and documented by the prescriber. Resident #24, who had diagnoses including traumatic brain injury, anxiety disorder, and dementia, was cognitively intact and had no behavioral symptoms according to the Minimum Data Set. Despite this, the resident received multiple as needed orders for Ativan over an extended period without the required 14-day reevaluation and documentation of rationale for continuation. Observations and interviews with staff indicated that the resident's anxiety was stable, and there were no recent behavioral issues, suggesting that the extended use of Ativan may not have been necessary. Interviews with various staff members, including the Nurse Practitioner, Consultant Pharmacist, Medical Director, and Registered Nurse Supervisors, revealed a lack of awareness and oversight regarding the 14-day limitation for as needed psychotropic medications. The Consultant Pharmacist and Medical Director acknowledged the oversight, and the Social Worker confirmed that the as needed Ativan order was incorrectly set for 30 days instead of 14. The Director of Nursing and other staff noted improvements in the resident's condition, further questioning the need for prolonged use of the medication without proper documentation and review.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 758 483.45(e)(4) [MEDICAL CONDITION] Drugs 1. The facility currently has [MEDICAL CONDITION] Medication Use policy that ensures residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is deemed necessary to treat a diagnosed specific condition that is documented in the clinical record. Resident #24's chart was reviewed by the Medical provider and PRN [MEDICAL CONDITION] order was discontinued, and a corrected PRN [MEDICAL CONDITION] order was written immediately with stop date of 14 days. Two (2) separate audits by the Director of Nursing and Pharmacy Consultant on 3/19/25 were completed to ensure [MEDICAL CONDITION] medication use accuracy in all medical records. Audits will continue twice per month for the next 6 months. 2. Nursing Staff were educated immediately by the Director of Nursing with an in-service reviewing Policy and Procedure, Continuing education regarding [MEDICAL CONDITION] Medications and PRN Medication Administration. RN and LPN staff completed this in-service by 3/25/2025. The Director of Nursing, Pharmacist Consultant and Social Worker meet once monthly to review resident [MEDICAL CONDITION] use. All residents are reviewed monthly/quarterly and as needed. Residents that need GDRs are determined and reviewed by the Director of Nursing/designee and Medical Director. 3. The Director of Nursing reviewed all Resident Care plans for [MEDICAL CONDITION] drug use. As stated in our [MEDICAL CONDITION] Medication Use policy, residents will not receive [MEDICAL CONDITION] drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. 4. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days except if the attending physician/designee believes that it is appropriate for the PRN order to be extended beyond 14 days. The Physician/designee will document any clinically contraindicated or specific conditions in clinical record along with their rationale and indicate the duration for the PRN order. 5. All (52) current resident’s medical records were audited to ensure all active PRN [MEDICAL CONDITION] medications have a 14-day stop date. If the order does not include the 14-day stop date, prescriber will be contacted and a corrected order will be issued. If the prescriber deems it appropriate to extend past 14 days, the prescriber will document rationale in the resident’s permanent medical record. An audit of the clinical record for PRN [MEDICAL CONDITION] Medications will continue twice monthly x 6 months by the DON/designee and/or Pharmacy Consultant. All audits will be reviewed quarterly for the next 6 months at QA/QAPI meetings. The Director of Nursing/designee will be responsible for the overall implementation of the plan of correction.
Penalty
A resident was administered PRN Ativan on three occasions, but documentation showed that non-pharmacological interventions were only attempted before two of those administrations. An LPN confirmed that there was no record of any intervention being tried prior to one of the doses, resulting in a deficiency related to the use of psychotropic medications.
A resident with dementia and behavioral disturbances received a PRN order for Lorazepam that was not limited to 14 days and lacked a documented rationale for continuation beyond this period. The medication was administered without evidence that non-pharmacological interventions were attempted first, and required documentation was missing.
The facility did not reassess a PRN psychotropic medication for a resident with severe cognitive impairment, allowing continued use without physician review, and also failed to complete an AIMS assessment for another resident receiving antipsychotic medication. Staff were unaware of the requirements for medication reassessment and AIMS completion.
Two residents received routine Seroquel administration without proper documentation of targeted behaviors, monitoring for adverse effects, or rationale for continued use. In both cases, there was no evidence of attempted gradual dose reduction (GDR) or clinical justification for not attempting GDR, and staff interviews confirmed these documentation gaps.
A resident admitted for hospice care with dementia and Parkinson's disease was prescribed lorazepam and quetiapine for anxiety and psychosis, but staff did not initiate monitoring for targeted behaviors or medication side effects until two days after starting the medications. Nursing staff and leadership confirmed that monitoring should have begun with the initiation of psychotropic medications, as required by facility policy.
A resident with moderate cognitive impairment was prescribed psychotropic medications, but the facility failed to complete and document required Gradual Dose Reductions (GDRs) as per regulatory standards. Only one GDR attempt was made for each medication over extended periods, and there was no supporting documentation for GDRs or contraindications. Staff were unclear on GDR requirements, and facility policy lacked specific time frames for GDR attempts.
Failure to Document Non-Pharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions (NPI) were provided or attempted prior to administering a psychotropic medication for one resident. Specifically, a resident was prescribed Ativan (Lorazepam) on an as-needed basis and received doses on three separate occasions. Documentation confirmed that NPIs were attempted before administration on two of those dates, but there was no documentation of any NPI being attempted prior to the administration on the third date. During interviews, an LPN explained that the facility's process is to attempt NPIs before administering psychotropic medications and that such attempts should be documented either in the electronic Medication Administration Record (eMAR) or in a progress note. Upon review of the resident's records, the LPN was unable to find any documentation indicating that an NPI was attempted before the administration of Ativan on the date in question, confirming the deficiency.
Failure to Limit and Document PRN Psychotropic Medication Orders
Penalty
Summary
Facility staff failed to ensure compliance with regulations regarding the use of as needed (PRN) psychotropic medications for a resident with dementia and behavioral disturbances. A physician order for Lorazepam, to be administered prior to blood draws, was written as a PRN order without a 14-day limitation or a specified duration and discontinuation date. The medical record did not contain documentation from the physician providing a rationale for continuing the PRN order beyond 14 days, as required by regulation. Additionally, review of the medication administration record showed that Lorazepam was administered to the resident, but there was no documentation indicating that non-pharmacological interventions were attempted prior to giving the medication. These findings were confirmed during interviews with the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of appropriate documentation and understanding of the requirements for PRN psychotropic medication orders.
Failure to Reassess PRN Psychotropic Medication and Complete AIMS Assessment
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary medications by not reassessing a PRN psychotropic medication as required. Specifically, a resident with severe cognitive impairment and diagnoses including depression and Alzheimer's Disease had a PRN order for trazodone to address restlessness and agitation. The order, initiated at admission, was not reassessed by the physician after the initial 14 days or at any subsequent time, despite ongoing use over several months. There was also no evidence that the resident was seen by behavioral health services for medication management. Facility staff, including the nurse and Director of Nursing, were unaware that the medication had not been re-evaluated as required by policy. Additionally, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for another resident who was receiving antipsychotic medication. This resident, admitted with diagnoses including suicidal ideations, depression, aphasia, and chorea, had a physician's order for daily risperidone. Review of the medical record showed no documentation that an AIMS assessment was completed, as required for residents on antipsychotic medications. Staff interviews revealed a lack of awareness and training regarding the completion and timing of AIMS assessments.
Failure to Monitor and Document Antipsychotic Use and GDR for Two Residents
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by policy and regulation. For one resident with Alzheimer's disease, dementia with agitation, major depressive disorder, and anxiety, Seroquel was administered routinely without identifying or monitoring resident-specific target behaviors or signs and symptoms of potential adverse consequences. Physician's orders for Seroquel did not specify targeted behaviors or monitoring parameters, and the medical record lacked documentation of monitoring for efficacy or adverse effects. For another resident with Alzheimer's disease, depression, and anxiety, Seroquel was also administered on a routine basis. The medical record did not contain a documented rationale for the use of Seroquel, nor was there evidence that a gradual dose reduction (GDR) was attempted or that a clinical contraindication to GDR was documented by the prescriber. Although a consultant psychiatric nurse practitioner recommended against GDR due to potential psychiatric destabilization, this recommendation was not reviewed or documented by the attending physician or nurse practitioner in the resident's record. Interviews with facility staff, including the Director of Nursing and Social Worker, confirmed that there was no documentation of resident-specific targeted behaviors, monitoring for adverse consequences, or rationale for continued use of Seroquel. The Director of Nursing acknowledged that these elements should have been documented but were not completed for the residents in question.
Failure to Monitor Behaviors and Side Effects for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring of a resident who was admitted under general in-patient hospice care with diagnoses including dementia, Parkinson's disease, and uncontrolled behaviors posing a danger to self and others. Upon admission, the resident was prescribed psychotropic medications, specifically lorazepam for anxiety, restlessness, agitation, and shortness of breath, and quetiapine fumarate for psychosis and unprovoked physical behavior. However, there was no documented evidence that monitoring for targeted behaviors such as anxiety and psychosis, or for side effects related to the use of these psychotropic medications, was initiated until two days after admission. Interviews with nursing staff and facility leadership confirmed that monitoring for behaviors and side effects should have been conducted from the time the medications were started. The facility's own policy required staff to monitor for adverse side effects associated with psychotropic medication use. The lack of timely monitoring was acknowledged by the RN, ADON, LVN, and DON, all of whom stated that such monitoring was expected and should have been implemented as soon as the medications were ordered.
Failure to Complete and Document Required Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a Gradual Dose Reduction (GDR) was completed for one resident reviewed for unnecessary medications. The resident, who was moderately cognitively impaired, was prescribed Sertraline for depression and Zyprexa for dementia with psychotic disturbance. Documentation showed only one GDR attempt for Sertraline in over two years and only one GDR attempt for Zyprexa in the previous thirteen months. There was no supporting documentation in the electronic health record (EHR) for a GDR on the date indicated in the Minimum Data Set (MDS), nor was there documentation from the pharmacy or provider requesting a GDR or supporting contraindications for GDR. Staff interviews revealed confusion regarding the requirements for GDRs, with staff referencing facility policy and pharmacy guidelines but unable to provide documentation supporting their practices. The facility's policy did not specify time frame requirements for GDR attempts, and no further documentation was provided to support that appropriate GDRs or contraindications had been addressed for the resident's psychotropic medications.
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