F0605

E

Psychotropic Medications Administered Without Corresponding Diagnoses

Albuquerque, New Mexico Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure psychotropic medications were prescribed and documented as medically necessary to treat specific, diagnosed conditions. For one resident with end stage renal disease, dependence on dialysis, paranoid schizophrenia, bipolar disorder, presbyopia, and post-traumatic stress disorder, record review showed an order for citalopram 10 mg at bedtime for depression. The Interim Director of Nursing (IDON) confirmed that the indicated use of citalopram is depression and that this resident did not have a diagnosis of depression. The IDON also confirmed that medications should be documented to treat specific conditions as diagnosed, and this was not done for this resident.

For another resident with lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism, record review showed orders for fluoxetine 20 mg daily and venlafaxine 75 mg daily, both indicated for depression, and trazodone 150 mg (2 tablets at bedtime) indicated for insomnia. During interview, the IDON confirmed that the indicated uses for fluoxetine and venlafaxine were depression and for trazodone was insomnia, and that this resident did not have diagnoses of depression or insomnia. The IDON further confirmed that medications should be documented to treat specific conditions as diagnosed and that this requirement was not met for these psychotropic medications.