F0684

D

Failure to Clarify Indication for Psychotropic Medication

Nampa, Idaho Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow professional standards of practice by not clarifying the indication for a psychotropic medication for one resident. The resident was admitted with multiple diagnoses including diabetes, protein calorie malnutrition, and dysphagia, and had undergone a gastrostomy tube placement. A hospital discharge summary documented that the resident had lack of sleep and depression related to increased stress and sleep difficulties from ongoing medical issues, and that psychiatry was consulted and started the resident on Mirtazapine nightly. However, the resident’s January 2026 MAR documented Mirtazapine 7.5 mg via G-tube at bedtime for appetite stimulant, which did not match the hospital documentation of use for insomnia and depression. During an interview, the DON reviewed the hospital progress notes and stated that the Mirtazapine was for the resident’s insomnia and depression, confirming that the indication on the MAR was not consistent with the hospital records and had not been properly clarified.

These practices had the potential to adversely affect or harm residents whose care and services were not delivered to accepted standards of clinical practice.