F0757

D

Antipsychotic Medication Initiated Without Assessment, Consent, or Proper Care Planning

Bremerton, Washington Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when Seroquel, an antipsychotic medication, was initiated and continued without proper assessment, diagnosis, or monitoring. The resident was admitted with encephalopathy related to glioblastoma, was moderately cognitively impaired, and required extensive assistance with most activities of daily living. A psychiatry note documented that the resident was confused and minimally engaged, with an impression of unspecified cognitive disorders worsening due to recent medical events, and specifically stated there was no obvious need for psychotropic intervention. Despite this, the former Director of Nursing Services obtained an order for Seroquel 50 mg every morning and 150 mg at bedtime for anxiety and depression, without documentation of behaviors or other clinical justification explaining why the medication was started.

There was no Psychopharmacologic Medication Informed Consent signed by the resident to show that risks, benefits, side effects, or the need for gradual dose reduction had been reviewed. The care plan later identified Seroquel incorrectly as an anxiolytic medication and, even when revised, did not include an appropriate assessment, non-pharmacologic interventions, or monitoring specific to an antipsychotic medication, nor did it address a plan for gradual dose reduction. When interviewed, the Director of Nursing Services stated they did not know why Seroquel had been started and acknowledged there was no documentation to support the drug regimen. The report states that this failure to complete a thorough evaluation before starting the medication and to provide necessary monitoring during therapy placed residents at risk for sedation, decreased quality of life, and death.