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F0605
D

Psychotropic Medications Used Without Approved Indications

Grand Island, Nebraska Survey Completed on 05-21-2025

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

The facility failed to ensure that psychotropic medications were prescribed and administered only for approved indications in accordance with facility policy and regulatory requirements. For one resident with hemiplegia, type 2 diabetes, dementia, and a history of stroke, Quetiapine, an antipsychotic medication, was ordered and administered for anxiety, which is not an FDA-approved indication for this drug. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and the medication was given routinely as per the physician's order. The Director of Nursing (DON) confirmed that anxiety was not an approved indication for Quetiapine. In another case, a resident with hydrocephalus, type 2 diabetes, and dementia was prescribed Mirtazapine, an antidepressant, for insomnia. The MDS showed the resident was cognitively intact and received the medication routinely. However, the resident did not have a diagnosis of insomnia documented in their medical record, and the DON confirmed that insomnia was not an approved indication for Mirtazapine. These findings demonstrate that the facility did not ensure psychotropic medications were used only for specific, diagnosed, and documented conditions as required.

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