Antipsychotic Medication Used for Dementia Contrary to Facility Policy
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident did not receive an antipsychotic medication for a diagnosis of dementia, contrary to the facility’s own policy. The 2025 policy titled "Monitoring of Anti-Psychotics" specified that residents were only to be prescribed antipsychotic medications if they had one of the listed diagnoses, and no form of dementia was included on that list. Despite this, physician orders dated 11/19/25 directed that Resident #10 receive quetiapine 25 mg every morning and 50 mg at bedtime for a diagnosis of vascular dementia, unspecified severity, with agitation. The December 2025 medication administration record showed the resident received both the morning and bedtime doses of quetiapine on multiple consecutive days from 12/01/25 through 12/11/25. During interviews, the DON confirmed that antipsychotic medications were not approved under facility policy for the treatment of dementia, and an LPN reported administering quetiapine for the resident’s aggression toward other residents but stated they did not know whether the medication was approved for treating dementia with aggression. The DON also identified that a total of 11 residents in the facility were receiving antipsychotic medications, indicating that the reviewed resident was among a broader group of residents on such therapy. The documentation and interviews together showed that the antipsychotic was ordered and administered for a dementia-related diagnosis that was not permitted under the facility’s antipsychotic monitoring policy, and that nursing staff lacked knowledge about whether the use of quetiapine for dementia with aggression was in accordance with approved indications.
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