F0552

D

Failure to Inform Resident Representative of Psychotropic Medication Risks and Alternatives

Somerset, Pennsylvania Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

Surveyors determined that the facility failed to inform a resident’s representative in advance about the risks, benefits, and treatment alternatives related to psychotropic medication dose increases. The facility’s policy on psychotropic medications, dated February 4, 2026, required that prior to initiating or increasing such medications, the resident, family, and/or representative be informed of the benefits, risks, alternatives, and any black box warnings, and that this discussion be documented in the clinical record. Review of the clinical record for Resident 4 showed that this required documentation was absent.

Resident 4’s quarterly MDS dated January 28, 2026, indicated cognitive impairment, limited ability to be understood, usual ability to understand others, no behavioral symptoms, receipt of hospice services, and use of psychotropic medications including antipsychotic and antidepressant drugs, with diagnoses of anxiety, depression, and dementia. A nursing note on October 30, 2025, documented a new hospice order to increase Seroquel to 50 mg twice daily for behaviors, and physician orders on October 31, 2025, and January 27, 2026, further increased Seroquel to 50 mg twice daily and then 100 mg twice daily. There was no documented evidence that the resident’s representative was informed in advance of the risks, benefits, and treatment alternatives before these dose increases, a lack of documentation confirmed by the DON during interview.