F0605

E

Psychotropic Medications Used Without Appropriate Diagnosis or Time-Limited PRN Orders

Roswell, New Mexico Survey Completed on 12-18-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure psychotropic medications were medically necessary, tied to appropriate diagnoses, and ordered in accordance with regulatory requirements. One resident was admitted with diagnoses including insomnia, major depressive disorder, and psychotic disorder. This resident had a physician order for PRN lorazepam 0.5 mg by mouth every 4 hours as needed for anxiety and restlessness, starting on 11/11/25. The December 2025 MAR showed the medication was administered multiple times during the month. However, the PRN lorazepam order was not limited to 14 days and did not specify a duration, and the resident did not have a diagnosis of anxiety. During interview, the DON confirmed the absence of a 14‑day limit or duration for the PRN psychotropic order and acknowledged that the resident lacked an anxiety diagnosis.

Another resident was admitted with diagnoses including schizophrenia, dementia, parkinsonism, major depressive disorder, and anxiety disorder. This resident had an order for olanzapine 10 mg by mouth twice daily for “mood,” starting 03/27/24, and trazodone 75 mg by mouth at bedtime for insomnia, starting 04/21/25. The December 2025 MAR showed the resident received olanzapine twice daily and trazodone daily from 12/01/25 through 12/15/25. The DON confirmed that “mood” was not an appropriate indication for olanzapine and that the resident did not have a diagnosis of insomnia despite receiving trazodone for that indication. The DON stated these practices did not meet her expectations and that medications should have an appropriate indication of use related to the resident’s diagnosis, and PRN psychotropics should either indicate duration or be limited to 14 days.