Inaccurate Assessment of Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident receiving antipsychotic medications. Record review showed a physician order dated 11/12/25 discontinuing the resident’s Olanzapine, an antipsychotic medication. However, the quarterly assessment dated 11/25/25 documented that the resident had received an antipsychotic medication daily during the seven-day look-back period. The same assessment showed the resident had a BIMS score of 10, indicating moderately impaired cognition for daily decision making, and listed diagnoses including dementia and depression. During an interview on 01/20/26 at 10:39 a.m., the DON stated that this assessment was inaccurate, confirming the discrepancy between the medical record and the assessment documentation. This deficiency involved 1 of 18 sampled residents reviewed for assessments, with the DON identifying that 80 residents resided in the facility at the time of the survey.
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