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F0605
D

Failure to Discontinue Unnecessary Psychotropic Medication

Ashland, Oregon Survey Completed on 05-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with diagnoses of PTSD and insomnia was admitted to the facility in September 2023. The clinical psychologist's management plan dated April 16, 2025, recommended transitioning the resident from Ambien, a sedative, to an alternative sleep aid, and noted the resident was open to trying a different medication. Despite this recommendation, medication administration records for April and early May 2025 showed the resident continued to receive Ambien nightly from April 1 through May 7, 2025. On May 8, 2025, the regional nurse confirmed that the resident had not been transitioned off Ambien as recommended and acknowledged that staff had not followed up on the psychologist's recommendation.

See complete original report
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