Failure to Implement Non-Pharmacological Interventions for Depression
Summary
A deficiency was identified when a facility failed to ensure that non-pharmacological interventions were implemented for a resident who was receiving psychotropic medication for depression. The facility's policy required that non-pharmacological interventions be attempted unless contraindicated, in order to minimize the need for psychotropic medication, use the lowest possible dose, or discontinue the medication. However, review of the medical record for a resident with a diagnosis of depression and cognitive impairment revealed that, despite ongoing episodes of depression manifested by crying spells, there was no documentation that non-pharmacological interventions were identified or implemented. The resident in question had a history of memory problems and severely impaired cognitive skills for daily decision making. The resident was prescribed mirtazapine, an antidepressant, to be taken at bedtime for depression as manifested by crying. Over a period of time, the resident experienced 56 episodes of depression, specifically crying spells, while on this medication. Despite these ongoing symptoms, the medical record did not show any evidence that alternative, non-drug interventions were considered or used to address the resident's depressive episodes. During interviews, both an LVN and the DON confirmed that the resident was receiving mirtazapine and had multiple episodes of depression, but they were unable to provide documentation of any non-pharmacological interventions being used. The lack of such interventions was contrary to the facility's own policy and federal requirements, resulting in the resident being at risk of receiving unnecessary psychotropic medication.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 89 was identified as affected by this concern. Resident is currently receiving a routine antidepressant medication. It was noted during an interview on 7/22/2025 that LVN 2 was unable to readily identify where non-pharmacological interventions (NPI) were documented in the medical record. On 7/22/2025, the DON educated LVN on how to locate NPIs in the care plan and the importance of documenting NPIs when resident behaviors are observed. Resident 89's plan of care was updated to include NPI for depression and making sure licensed nurse is documenting Resident 89's behavior when it occurs and when NPI was provided. 2. Identify Other Residents Who May Have Been Affected by the Deficient Practice: Residents receiving psychotropic medications may have been impacted by this issue. On 8/4/2025, the DON and Unit Manager audited 10 random residents' medical records receiving psychotropic medication and found no other issues noted. From 8/5/2025-8/8/2025, the Director of Nursing (DON) or designee in-serviced all licensed nurses about residents receiving psychotropic medication, in particular routine psych medications, to include NPIs and recording behavior per facility policy and procedure. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The DON or designee will oversee ongoing education and compliance monitoring. All residents on psychotropic medications will continue to have care plans that include individualized NPIs. From 8/5/2025, licensed staff received continued education on documenting behavioral observations and corresponding NPIs in the medical record. Medical records or designee will review all new psychotropic medication orders daily, including new admissions and re-admissions, and report findings to the DON. New orders will be reviewed in clinical meetings to ensure NPIs are considered and included in the resident's care plan by the interdisciplinary team (IDT), as appropriate. Resident's plan of care will be updated per facility policy and procedure. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance: Integrate QA Process: The DON or designee will monitor the effectiveness of the process. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 194 was affected by this deficient practice. Resident 194 was no longer in the facility. On 7/22/2025, the Medical Record Director sent a copy of the resident 194 Notification of discharge to the ombudsman. On 8/5/2025, the Administrator in-serviced Medical Records, Social Services, and the Case Manager on the process of notifying the ombudsman of any resident transfer or discharge per facility protocol. From 8/5/2025-8/8/2025, the DON in-serviced all licensed nurses about the facility policy and process for notifying the ombudsman about resident discharges and transfers. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents discharged were potentially affected by this deficient practice. On 8/5/2025, medical records were audited for transfers and discharges in the last 30 days to ensure notification of the ombudsman was done, and no other issues were noted. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The administrator or designee will oversee the process. Social Services and the Case Manager will notify the ombudsman for any resident discharge to the community, and Medical Records will notify the ombudsman for any resident transferred to an acute setting. Medical records will audit residents' medical records when discharged or transferred to ensure notification of the ombudsman was completed. The administrator or designee will review the notification of ombudsman log monthly for three months to ensure it's completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with COPD, anxiety, and PTSD had a PRN lorazepam order entered for palliative care related to COPD without an appropriate clinical indication documented. The care plan directed staff to give meds as ordered by the physician, and the CNO later stated the lorazepam indication should have been shortness of breath or anxiety.
Failure to document GDR or rationale for psychotropic use: A resident with dementia, TBI, anxiety, and depression was receiving escitalopram and quetiapine, with no behaviors noted during the assessment period. Pharmacy recommended review of continued use and a clinical rationale if doses were maintained, but the record did not show a GDR attempt or documented rationale for not completing one; the DON stated that documenting the resident as stable was not an appropriate rationale.
PRN antipsychotic order lacked required stop date. A resident with severe cognitive impairment, dementia, anxiety, depression, wandering, and behavioral symptoms received PRN Haloperidol repeatedly, but the order was entered as indefinite even though it was written for 14 days. Staff said the medication was used when redirection failed and behaviors disturbed others, and the LPN, RN, and DON confirmed PRN psychotropic meds should have an end date and be re-evaluated after 14 days.
A resident with depression, anxiety, and moderate cognitive impairment received PRN Hydroxyzine on multiple occasions, but the record did not show that individualized non-pharmacological interventions were tried or ineffective before administration. The chart also lacked the prescriber’s clinical rationale and duration for continuing the PRN psychotropic order beyond the 14-day limit.
A resident with anxiety and depression was prescribed Buspirone for anxiety as manifested by restlessness/inability to relax, but the order did not identify the resident’s specific behaviors. Staff described the resident’s restlessness differently, the CNA did not know the signs and symptoms, and the RN noted the MAR did not reflect the resident’s anxiety level. The DON stated the documentation was not accurate because staff had different ideas of what restlessness meant, and the facility policy required psychotropic use only for a specific, diagnosed, and documented condition.
A resident had an active PRN order for Lorazepam for agitation that exceeded the 14-day limit for psychotropic medications. The DON confirmed the order was over 14 days, and the PA stated there was no documented rationale for the medication in the clinical record.
Inappropriate Indication for PRN Lorazepam
Penalty
Summary
The facility failed to ensure medications were administered with an appropriate clinical indication for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. The resident’s care plan, revised 5/27/26, directed staff to give medications as ordered by the physician. Physician orders showed lorazepam 2 mg/mL, 0.5 mL by mouth every 4 hours as needed, ordered for palliative care related to COPD and initiated on 6/29/26. During review on 7/9/26 at 2:45 PM, the CNO reviewed the lorazepam order and stated the indication should be shortness of breath or anxiety.
Failure to Document GDR or Rationale for Psychotropic Use
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted, or that a clinical rationale was documented for continued psychotropic use for one resident. The resident’s MDS assessment identified mildly impaired cognition, dependence on staff for ADLs, and diagnoses of dementia, traumatic brain injury, anxiety, and depression. The resident reported feeling down, depressed, or hopeless several days over the prior 2 weeks, and no behaviors were noted during the assessment period. The resident was receiving escitalopram 5 mg daily for generalized anxiety and quetiapine 100 mg at bedtime for unspecified dementia with agitation. The pharmacy medication review recommended that the physician assess continued use of both medications and provide a clinical rationale if the current doses remained appropriate. The physician reviewed and accepted the report, and the NP later documented that the medications were to continue as is, with the resident’s mood stable and no changes recommended. However, the record did not contain documentation that a GDR had been completed or that a rationale for not completing a GDR had been documented. The DON stated that documenting stable was not an appropriate rationale for continued use.
PRN Antipsychotic Order Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication order had a defined stop date and was limited to 14 days without a documented rationale for extension for one resident. The resident had severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression, and exhibited verbal behavioral symptoms, behavioral symptoms not directed at others, and wandering. The resident's mood/behavior care plan directed staff to administer medications per MD/NP orders, monitor for side effects, notify the provider with concerns, and refer to behavioral services as needed. The resident's order review history showed Haloperidol 1 mg by mouth every 4 hours as needed for 14 days starting 4/28/26, but the order lacked an end date and was entered as indefinite. The resident received PRN Haloperidol 16 times in June and once during the first six days of July. Staff interviews confirmed the medication was being used when redirection did not work and when behaviors disturbed other residents, and the LPN verified the order had been mistakenly given beyond the 14-day end date. The RN and DON also confirmed PRN psychotropic medications should have an end date and be re-evaluated after 14 days, and the facility policy stated PRN antipsychotic medications are only effective for 14 days.
Failure to Document Non-Pharmacological Interventions and PRN Psychotropic Order Extension
Penalty
Summary
The facility failed to document that individualized non-pharmacological interventions were attempted or found ineffective before administering PRN Hydroxyzine to Resident 35, and it also failed to document the prescribing practitioner’s clinical rationale and specified duration for continuing the PRN psychotropic medication beyond the federal 14-day limit. Resident 35 was admitted with diagnoses including depression and anxiety and was assessed as moderately cognitively impaired on the Quarterly MDS with a BIMS score of 12. Physician orders showed Hydroxyzine 25 mg was ordered PRN at bedtime for anxiety for 14 days, then later changed to PRN twice daily. The MAR showed the medication was administered on multiple occasions, but the clinical record did not identify documentation that non-pharmacological interventions were attempted before any of the administrations. The record also did not contain documentation from the prescribing practitioner supporting continuation of the PRN Hydroxyzine order beyond 14 days or specifying the duration of the extension.
Unclear indication documented for Buspirone use
Penalty
Summary
The facility failed to ensure that one sampled resident reviewed for unnecessary medications had a specific indication documented for the use of Buspirone. The resident was admitted with diagnoses including anxiety and depression, and the physician order dated 6/2/2026 directed Buspirone HCL 15 mg by mouth twice daily for anxiety as manifested by restlessness/inability to relax, but the order did not identify the resident’s specific behavior associated with restlessness or inability to relax. The resident’s MDS dated 6/5/2026 indicated moderate cognitive impairment and need for partial/moderate assistance with several activities of daily living, and also noted anxiety and depression. During interviews, staff gave different descriptions of the resident’s restlessness, including pacing, asking about appointments, complaining of pain, inability to sleep, walking around, and asking for pain medication. One CNA stated she did not know the resident’s signs and symptoms of restlessness. RN 2 stated the MAR for 6/30/2026 should have reflected the resident’s anxiety level but did not. The resident’s RP stated the resident’s sign of restlessness was isolating himself and reported that the resident texted her about having anxiety from 10:30 AM until 7 PM on 6/30/2026. The DON reviewed the MAR and stated it was not accurate because staff had different ideas of what restlessness was, and stated the resident should have the correct manifestation of anxiety reflected in the physician order and MAR. The facility policy stated psychotropic medications are to be used only when a practitioner determines the medication is appropriate to treat the resident’s specific, diagnosed, and documented condition.
PRN Psychotropic Order Exceeded 14-Day Limit
Penalty
Summary
The facility failed to ensure that a PRN order for a psychotropic medication was limited to 14 days for Resident #5. Review of the resident’s MAR showed an active order for Lorazepam 0.5 mg by mouth every 4 hours as needed for agitation, with a start date of 6/12/26. During interview, the DON confirmed that the Lorazepam order was greater than 14 days, and the PA stated that no rationale for the Lorazepam had been documented in the clinical record. The facility policy reviewed by surveyors stated that psychotropic medications are not to be prescribed or given on a PRN basis unless necessary to treat a diagnosed specific condition documented in the clinical record, and that PRN orders for psychotropic medications are limited to 14 days.
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