F0605

D

Failure to Ensure Appropriate Indications and 14-Day Limits for Psychotropic Medications

Mcpherson, Kansas Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure appropriate indications and documentation for psychotropic medication use, including antipsychotic and PRN antianxiety drugs. One resident with diagnoses of dementia, depression, Parkinson’s disease, and encephalopathy was admitted post-hospitalization and had severely impaired cognition, requiring staff assistance with most ADLs. This resident received Seroquel 25 mg twice daily for a diagnosis of dementia with agitation. The care plan documented monitoring for side effects and effectiveness, but the electronic medical record lacked a documented physician rationale for the continued use of Seroquel, including documentation of unsuccessful attempts at nonpharmacological symptom management and a risk-versus-benefit analysis. An administrative nurse confirmed that the resident was receiving an antipsychotic with a diagnosis of dementia, which was identified as an inappropriate indication under facility policy, and that the physician and consultant pharmacist had recognized the need for a different diagnosis.

The facility’s own Antipsychotic Medication Administration policy required that antipsychotics only be used when necessary to treat a specific, documented condition and that orders include a diagnosis, condition, or indication for use from a defined list of acceptable conditions. The policy also required comprehensive assessment, routine dose reduction, and behavioral interventions unless clinically contraindicated. Despite these requirements, the documentation for the resident on Seroquel did not include the necessary physician rationale or evidence of nonpharmacological interventions attempted prior to or alongside antipsychotic use, as required by the policy.

The deficiency also includes failures related to PRN antianxiety medications for two other residents with dementia, depression, and anxiety diagnoses and severely impaired cognition. One resident had a physician’s order for alprazolam 0.5 mg by mouth every eight hours PRN for anxiety, and another had an order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety. Both orders lacked a 14-day stop date or any specified duration. Their electronic medical records did not contain evidence of a physician’s rationale for extended PRN use, including a risk-benefit rationale statement and duration, as required by the facility’s Psychotropic Medication Use policy. Nursing staff acknowledged that PRN psychotropic orders were supposed to have a 14-day stop date and that the physician should reassess the residents to determine ongoing need, but this had not been implemented in these cases.