F0757

D

PRN Antipsychotic Administered Without Indication, Behavior Care Plan, or Required Documentation

Jamesville, New York Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs, specifically related to PRN antipsychotic use without adequate medical rationale or documentation. Facility policy on psychotropic medication required identification of underlying causes of behaviors, use of individualized non-pharmacological interventions, and clear indications for PRN antipsychotics, including specific target symptoms and documentation of post-medication effects. Despite this, the resident’s records did not contain a behavior care plan or personalized behavioral interventions, and the Resident Care Record lacked any information on behavioral symptoms or related interventions.

The resident had diagnoses including unspecified dementia with behavioral disturbance and osteoporosis with a pathological hip fracture, and an MDS assessment documented severely impaired cognition, no behaviors, and a need for partial to moderate assistance with most ADLs. A comprehensive care plan addressed potential adverse effects from daily antipsychotic use but did not list an associated diagnosis and did not include a separate behavior care plan. The resident was admitted from the hospital with a PRN quetiapine order for agitation when unable to be redirected and with harm to self and others, and the facility’s admission orders continued quetiapine 12.5 mg PO in the evening as needed for 14 days. The NP’s history and physical documented dementia with behavior disturbances and other medical conditions and stated a plan to give PRN quetiapine for agitation, but there were no documented behaviors or related diagnosis specifically tied to the quetiapine in the record.

The MAR showed the resident received PRN quetiapine on four occasions, yet there was no documentation of behaviors, non-pharmacological interventions attempted, or post-medication effectiveness for three of those administrations. A nursing progress note for one administration described restlessness, irritability, and reported aggression, with snacks, redirection, and incontinence care attempted, but did not specify the exact aggressive behaviors or the outcome after interventions and medication. The resident’s health care proxy reported difficulty keeping the resident awake, difficulty with eating coordination, and trouble obtaining information about medications, and stated that quetiapine had been given at night without notes explaining why, despite the resident not typically exhibiting agitation or aggression. Interviews with staff revealed inconsistent understanding and practice regarding documentation and indications for PRN antipsychotic use: one LPN described giving quetiapine for aggression and attempts to leave, but acknowledged missing documentation; another LPN could not recall the reason for administration; the RN Unit Manager confirmed there was no behavior care plan and that notes were missing for most PRN uses; the NP stated agitation alone was not an indication and that non-pharmacological interventions and their effectiveness should be documented; the Medical Director indicated the drug was used for agitation and sleep and that PRN antipsychotics were routinely used for sleep; and the DON stated that if an as needed antipsychotic was administered, a corresponding nurse’s note was expected. Collectively, these findings show the resident received PRN antipsychotic medication without documented medical necessity, without required behavioral assessments and care planning, and without consistent documentation of non-drug interventions or medication effects, contrary to facility policy and regulatory requirements.