F0757

D

Unnecessary PRN IM Antipsychotic Use Without Adequate Indications or Documentation

Dallas, Texas Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary psychotropic medication, specifically PRN intramuscular (IM) Haldol, and to ensure adequate indications and documentation for its use. The resident was an elderly male with metabolic encephalopathy, vascular dementia, diabetes, insomnia, and previously documented but later unsubstantiated diagnoses of schizophrenia and schizoaffective disorder. A quarterly MDS showed severe cognitive impairment with no documented delirium, negative mood, or verbal/physical behaviors toward others. The resident required moderate assistance with ADLs, used a walker, and was frequently incontinent. His care plan initiated in late December did not identify behaviors or psychotropic medication use and did not address acute behavioral incidents that occurred later in the month or the new PRN psychotropic orders.

The resident’s psychotropic regimen included Seroquel for agitation, Depakote sprinkles for mood disorder, Trazodone for agitation and dementia, and Remeron for insomnia. A psychiatric NP evaluation shortly before the incidents documented the resident as calm, with dementia and insomnia, and noted no supporting evidence for schizophrenia or schizoaffective disorder, recommending removal of those diagnoses. Subsequent physician orders included a one-time IM Haldol dose for restlessness and agitation, and PRN Xanax for restlessness and agitation. The MAR showed administration of PRN Xanax and PRN IM Haldol, but the behavior monitoring section did not document any behaviors at the time of PRN administration. Nursing notes described the resident as having outbursts, yelling “mama, mama,” and attempting to kick staff, with reports of aggressive behavior and knocking down tables and chairs, but these behaviors were not reflected in the behavior monitoring logs or care plan.

On one occasion, staff reported the resident resisted incontinent care, was taken to the dining room, and began yelling and interacting with furniture, after which he was returned to his room and later given PRN Xanax. On another morning, the nurse described the resident as destructive and combative in bed, kicking at staff, and decided to administer IM Haldol based on an existing order, stating that oral Xanax had been ineffective because the resident spit it out. Other staff interviews provided differing accounts, with one CNA stating the resident was not normally aggressive, that she did not see him flip tables or chairs, and that he could be calmed with soft redirection, while describing other staff using loud, commanding voices. The facility’s own antipsychotic policy required that antipsychotics for dementia be used only after other causes of behavior were addressed, that behaviors present a danger to the resident or others, that behavioral interventions be attempted, and that PRN psychotropics only be used for specific documented conditions. A clinical leader acknowledged errors including lack of psychotropic medications on the care plan, lack of documented behaviors, and behavior monitoring logs showing zeros despite PRN psychotropic use, and stated that IM antipsychotics should not be used to compel residents to comply with care. The administrator stated IM antipsychotics should only be used when a resident posed a threat to self or others and that resisting care alone would not justify IM antipsychotic use, while affirming residents’ right to refuse care.

An observation of the resident after these events found him in a wheelchair at lunch with a full plate of food, eyes closed, slightly slumped, and only slowly beginning to eat after being roused, remaining non-responsive to questions and keeping his eyes closed. No visible injuries were noted. The facility’s antipsychotic policy also specified that antipsychotics should not be used when the only symptoms were restlessness or uncooperativeness and that residents should not receive PRN psychotropics unless necessary to treat a specific documented condition. Despite this, the resident received PRN IM Haldol in the context of resistance to care and combative behavior without clear documentation of danger to self or others, without adequate behavior documentation on the MAR or behavior logs, and without corresponding updates to the care plan, leading surveyors to determine that the resident’s drug regimen was not maintained free from unnecessary drugs.