F0740

D

Failure to Use Non-Pharmacological Interventions and Obtain Consent Before Extensive Psychotropic Use

Troy, Michigan Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure necessary behavioral health care and services for a resident with dementia and Alzheimer’s disease, including consistent use of non-pharmacological interventions, appropriate indications for psychotropic medications, individualized behavioral care planning, and monitoring of behavioral health services. The resident was admitted with multiple diagnoses including dementia, Alzheimer’s disease, falls, major depressive disorder, and nasal bone fractures following a fall with syncope. An MDS assessment showed a BIMS score of 3, indicating severely impaired cognition and dependence on staff for all ADLs. A care plan addressing impaired communication related to confusion and a language barrier (primary language Arabic) was present, and a behavior care plan for actual behavior problems related to dementia with episodes of yelling and screaming was not initiated until ten days after admission.

On multiple occasions, the NP and medical team ordered and adjusted psychotropic medications in response to reports of agitation, yelling, and screaming without consistent nursing documentation of the observed behaviors or of non-pharmacological interventions attempted beforehand. On one date, the NP documented increasing agitation, with reports from nursing staff and residents that the resident had been up all night screaming and yelling and that staff were unable to distract or redirect the behavior; Xanax 0.25 mg was added for anxiety, with an intervention to monitor non-pharmacological interventions. However, there was no corresponding nursing documentation of the agitation throughout the night and morning and no documentation of non-pharmacological interventions attempted. Over subsequent days, the NP discontinued Xanax and ordered Ativan 0.5 mg BID, a one-time dose of Seroquel 25 mg, and Seroquel 25 mg at bedtime, later increasing Seroquel to 50 mg in the evening and Xanax to 0.5 mg at bedtime, while continuing Zoloft and Remeron. The record showed no prior diagnosis of psychosis or anxiety, no documentation explaining why Ativan was added BID on a later date, and no documentation of behavioral descriptions or non-pharmacological interventions before administration of a one-time Ativan dose for reported anxiety and agitation.

The facility also failed to obtain informed consent for multiple psychotropic medications and for behavioral health services, despite a policy requiring psychotropic informed consent before initiating or increasing such medications and a documented Statement of Capacity indicating the resident was incapable of making informed medical decisions, activating the daughter’s DPOA authority. A physician order for psychiatric services to evaluate and treat as indicated was present, but the record lacked evidence of behavioral health consultation or specialized mental health services arranged as referenced in the care plan. The behavior care plan, initiated several days after admission, included interventions such as administering medications as ordered, documenting behaviors and responses, using calm approaches, diversion, removal from situations, identifying underlying causes, and providing appropriate activities, but the record did not show consistent implementation or monitoring of these interventions. Interviews with the DSS and DON confirmed lack of involvement in behavioral planning, lack of consultation with behavioral health services, absence of team discussion prior to psychotropic use, and absence of behavioral monitoring and oversight of multiple psychotropic medications with similar classifications, with no further explanation or documentation provided by the end of the survey.

Additionally, the facility did not implement interventions to monitor for adverse reactions or side effects of the antipsychotic and antianxiety medications administered, contrary to its Psychoactive Medication Management policy, which emphasized minimizing psychotropic use and using non-pharmacological interventions as the first choice. The care plan for potential fluctuations in mood referenced arranging specialized mental health services as indicated on the Level II assessment, but the record did not show that such services were arranged or utilized. The combination of missing behavior documentation, lack of non-pharmacological intervention records, absence of informed consent, delayed and insufficiently individualized care planning, and lack of monitoring for adverse effects collectively led to the cited deficiency for failing to provide necessary behavioral health care and services for this resident.

Interviews further highlighted gaps in the facility’s behavioral health processes. The DSS, who started employment around the time of the resident’s stay, could not clearly identify the resident’s targeted behaviors beyond falls and attempts to get out of bed and reported no involvement in the behavioral plan of care or implementation of non-pharmacological interventions. The DSS also confirmed that behavioral health services were not consulted for the resident and acknowledged that the IDT should have met to discuss behavioral and medication needs and then approached the resident’s daughter for psychotropic medication consent. The DON identified the resident’s targeted behaviors as yelling out and being resistive to care and stated that the resident was being followed by the medical team but did not believe the resident had been referred to behavioral health services. The DON acknowledged concerns about multiple psychotropic administrations without documentation of prior non-pharmacological interventions, lack of oversight of multiple psychotropics of the same class, and lack of behavioral monitoring and management, with no additional documentation provided to address these issues.