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 dementia, depression, diabetes, and CHF was receiving hospice care and had an open-ended PRN order for Haldol for agitation/restlessness. The record showed no documented face-to-face provider evaluation or justification for continued use after the consultant pharmacist twice recommended discontinuation under the 14-day PRN antipsychotic limit. Staff also noted the medication made the resident sleepy, and the MAR showed it was administered during the review period.
Failure to ensure appropriate use of an antipsychotic medication for a resident with dementia and depression. The resident was prescribed Risperidone for dementia with behaviors, but the record had no target-behavior monitoring order and no documentation of admission review for the psychotropic. An LPN, the Social Services Director, and the DON stated the diagnosis was not appropriate for Risperidone and that the resident should have had related behaviors monitored.
Failure to assess and document antipsychotic side effects for a resident receiving quetiapine for Parkinson’s disease and behavioral disturbance with agitation. The resident had moderately impaired cognition, needed staff help with ADLs, and was observed with a flat affect and mild finger tremor. Although an AIMS order was in place, the record showed incomplete sign-offs and no documented assessment results, and staff stated AIMS was used to monitor for side effects and should be documented in the medical record.
Psychotropic Medication Monitoring Failures: The facility did not document side effect monitoring for residents receiving antidepressant and antipsychotic medications, and orthostatic BP monitoring ordered for several residents was incomplete or showed identical readings across positions. Residents with severe cognitive impairment and multiple diagnoses, including dementia, schizophrenia, and cardiovascular conditions, were receiving psychotropic medications, but the EHR lacked evidence of ongoing monitoring for adverse effects. Staff interviews confirmed monthly orthostatic BP checks should include lying, sitting, and standing readings and that side effect monitoring was not yet in place.
PRN lorazepam orders for two residents with anxiety lacked required stop dates. One resident had intact cognition and documented antianxiety medication use, while the other had documented psychotropic use and impaired cognition; both had care plans to monitor for side effects, and an RN confirmed the orders did not include the stop date required by facility policy for PRN psychotropic meds.
A resident with dementia, UTI, diabetes, and acute pyelonephritis was prescribed and given Seroquel for agitation even though the record did not document behaviors or agitation. The EHR and MDS showed no indication for antipsychotic use, and staff stated the order did not meet expectations.
Failure to Review and Justify Continued PRN Antipsychotic Use
Penalty
Summary
The facility failed to review and justify the continued use of a PRN psychotropic medication for a resident who had moderate cognitive deficit, required moderate assistance with most ADLs, and was under hospice care for end-stage heart failure. The resident’s record showed diagnoses including CHF, dementia, diabetes, and depression, and the quarterly MDS noted no hallucinations, delusions, or behaviors during the observation period. The active physician orders included haloperidol 1 mg every four hours PRN for agitation and restlessness with an open-ended end date. The resident’s care plan identified psychotropic medication use for depression and anxiety, with approaches that included administering medications as ordered and documenting three interventions before giving the PRN medication. The consultant pharmacist twice recommended discontinuing the PRN Haldol because federal guidelines limited PRN antipsychotic orders to 14 days unless the attending physician evaluated the resident for appropriateness of renewal. One recommendation was signed by the physician with a comment that the resident was a hospice patient, but the record did not show a face-to-face provider visit or other documented justification for continued use, and the second recommendation had no physician response documented. The PRN MAR showed Haldol was administered on two occasions during the review period, and the medication order remained open-ended. During observation, the resident was noted hollering that she needed to use the bathroom, then was assisted to a recliner and fell asleep; staff stated she had been up until 3:00 a.m. An LPN stated the Haldol made the resident sleepy and was usually not given during the day so she could eat, while the DON stated PRN psychotropic medications should have a 14-day review and the facility’s policy also limited PRN psychotropic orders to 14 days unless the attending provider evaluated the resident.
Failure to Monitor and Justify Antipsychotic Use
Penalty
Summary
The facility failed to ensure the use of an antipsychotic medication was appropriate for one sampled resident, Resident 50, by not providing adequate monitoring or an appropriate indication for its use. Resident 50 was admitted with diagnoses of dementia with behaviors and depression, and the record also showed PASRR findings of depression, anxiety, and later severe depression. The provider ordered Risperidone daily at bedtime for dementia with behaviors starting 03/31/2026, but the electronic health record contained no order to monitor target behaviors related to the antipsychotic medication. The record also showed no documentation that Resident 50 was reviewed on admission for the use of an antipsychotic medication. During interviews, an LPN stated the diagnosis of dementia with behaviors was not an appropriate diagnosis for an antipsychotic medication and that target behaviors should have been monitored but were not. The Social Services Director stated the resident should have been reviewed in the monthly psychotropic meeting on admission, that dementia with behaviors was not an appropriate diagnosis for Risperidone, and that related behaviors should have been monitored. The DON stated the resident should have been reviewed in the monthly psychotropic meeting, had target behaviors monitored, and had an appropriate diagnosis for the antipsychotic.
Failure to Assess and Document Antipsychotic Side Effects
Penalty
Summary
The facility failed to assess for potential side effects of an antipsychotic medication for one resident who was reviewed for unnecessary medications. The resident’s quarterly MDS identified moderately impaired cognition, rejection of care one to three days, and dependence on staff for dressing, bed mobility, and toileting. The care plan stated the antipsychotic medication was being used for Parkinson’s disease and directed nursing staff to monitor for adverse effects and document findings. The physician order included quetiapine fumarate 25 mg by mouth daily for Parkinson’s disease and behavioral disturbance with agitation, along with 50 mg by mouth daily for the same indications. The resident also had a nursing order to complete an AIMS assessment every three months, but the record showed inconsistent completion and documentation. The TAR indicated the AIMS assessment was signed off as completed on three consecutive days in April, yet no assessment results were documented in the resident’s record. In May, the AIMS sign-off was blank and no assessment results were documented. In early June, no AIMS assessment had been signed off or documented. During observation, the resident was seated in a wheelchair with a flat affect and a mild tremor in the fingers. Staff interviews confirmed that AIMS assessments were intended to monitor side effects and were to be documented in the medical record.
Psychotropic Medication Monitoring and Orthostatic BP Documentation Failures
Penalty
Summary
The facility failed to ensure residents receiving psychotropic medications were adequately monitored for side effects and orthostatic blood pressures as ordered. Review of records for 4 of 6 residents identified for psychotropic medication monitoring showed no evidence that side effect monitoring had been implemented for residents receiving antidepressant, antipsychotic, or other psychotropic medications. R7 had moderate cognitive impairment and diagnoses including DVT, hypertension, BPH, renal insufficiency, diabetes mellitus, and CVA. R7 received escitalopram 20 mg daily for depression, but the EHR did not show evidence of side effect monitoring related to the medication. R10 had severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, atrial fibrillation, hypertension, and non-Alzheimer's dementia. R10 received brexpiprazole 1.5 mg twice daily for agitation related to dementia and haloperidol 2 mg daily for delusions related to unspecified dementia, but the EHR did not show evidence of side effect monitoring for these antipsychotics. R41 had severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, hypertension, PVD, hyperlipidemia, arthritis, Alzheimer's disease, stroke, and non-Alzheimer's dementia. R41 received risperidone 0.25 mg three times daily for hallucinations, and the EHR did not show evidence of side effect monitoring. R91 had severe cognitive impairment and schizophrenia and received olanzapine and risperidone for paranoid schizophrenia, but the EHR did not show evidence of side effect monitoring. The record also showed failures to obtain and document orthostatic blood pressures as ordered for R10, R41, and R91. For R10, monthly orthostatic blood pressure documentation contained identical readings across lying, sitting, and standing positions on multiple dates. For R41, some monthly orthostatic blood pressure checks were documented as refused, with no evidence the monitoring was attempted again later, and other entries showed identical readings in all positions. For R91, one monthly entry lacked standing blood pressure and pulse documentation, and another showed identical readings in all positions. Staff interviews confirmed orthostatic blood pressures should be completed monthly in lying, sitting, and standing positions, that identical readings in all positions were not expected, and that side effect monitoring for psychotropic medications was not yet in place.
PRN Lorazepam Orders Lacked Required Stop Dates
Penalty
Summary
The facility failed to obtain a stop date for PRN lorazepam orders for two residents. One resident had a diagnosis of anxiety, intact cognition with a BIMS score of 14, and documentation in the EMR showing use of antianxiety medication during the assessment period. Her psychotropic drug use CAA and care plan both reflected anxiety and monitoring for side effects of antianxiety medication, but the physician order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety, ordered 04/08/2026, did not include a stop date. Administrative Nurse D confirmed on 06/03/2026 that the PRN lorazepam order lacked the required stop date. The second resident also had a diagnosis of anxiety and psychotropic medication use documented in the EMR and CAA. Her MDS assessments showed varying cognitive impairment, including a BIMS score of 6 on one assessment and 11 on another, and her care plan instructed staff to monitor for side effects of antianxiety medication. The EMR order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety, ordered 10/19/2025, also lacked a stop date. Administrative Nurse D confirmed on 06/03/2026 that this PRN lorazepam order did not have the required stop date, consistent with the facility policy limiting PRN psychotropic medications to no more than 14 days unless extended with documented rationale and a specific duration.
Unnecessary Antipsychotic Use Without Documented Indication
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication use when Resident 65 was prescribed and administered Seroquel for agitation without documented behaviors or agitation in the record. Resident 65 was admitted with diagnoses including UTI, diabetes, dementia, and acute pyelonephritis, and was not able to communicate needs. Observation showed the resident sitting in a wheelchair by the nurse’s station with head down and eyes closed on multiple occasions. Review of the EHR showed progress notes from 04/30/2026 through 05/15/2026 did not document behaviors or agitation, and the admission MDS dated 03/26/2026 did not show behaviors or indications for antipsychotic use. During interview, the LPN/Resident Care Manager stated the facility’s process was to first rule out infection, environmental factors, and pain, then refer to mental health, and stated the Seroquel order did not meet expectations. The DON also stated the resident should have indications for antipsychotic use and that this did not meet expectation.
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