F0684

G

Failure to Follow Hospice-Directed Psychotropic Regimen Resulting in Agitation and Fall

Chanute, Kansas Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a hospice resident received necessary care and his personalized, physician‑ordered medication regimen to manage terminal agitation and promote comfort. The resident had a history of cerebral infarction, depression, anxiety, psychosis, insomnia, impaired balance, lower extremity impairment with a prosthesis, and functional dependence in multiple ADLs. Care Area Assessments identified risks for further ADL decline, falls, incontinence, skin breakdown, pain, increased falls, impaired balance, and worsening depression and anxiety. The resident’s care plan documented he was on hospice for end‑of‑life care related to a terminal cerebral infarction and that staff were to coordinate care with hospice, notify hospice of any change in condition or medication changes, and provide medications as ordered while monitoring for effectiveness and side effects.

The resident’s EMR showed he was receiving clonazepam 0.5 mg twice daily for anxiety related to altered mental status and Seroquel for dementia with distressing psychotic features. A provider order then added scheduled lorazepam (Ativan) 0.5 mg three times daily for agitation and irritability and admitted the resident to hospice. On hospice admission, most medications were discontinued, but clonazepam, lorazepam, Seroquel, Tylenol, Lantus, and PRN Tramadol were continued. Shortly afterward, an administrative nurse questioned why the resident had both scheduled Ativan and clonazepam, asserted the resident could not be on both, and required that the primary care provider be called to choose one or the other. A subsequent provider order discontinued clonazepam and continued lorazepam and Seroquel. Hospice was not informed of the discontinuation, and hospice staff later confirmed they had not received an order to stop clonazepam and only learned from facility staff that it had been stopped.

Following the abrupt discontinuation of clonazepam, documentation showed the resident became increasingly agitated, confused, and distressed. Nursing notes described the resident becoming upset, refusing medications, expressing paranoid thoughts that staff were trying to poison him, picking up a folding table, threatening to throw it through a door, and requiring repeated staff interventions before eventually taking medications. Additional notes recorded the resident yelling for help, attempting to put on his prosthetic leg to “get some things out of the truck,” refusing care, being visibly upset and tearful, expressing confusion about his location and his daughter’s whereabouts, and having delusions about the Air Force being in the facility. The resident experienced an unwitnessed fall while trying to go downstairs, resulting in a skin tear and apparent discomfort, and he required increased use of narcotic pain medication after clonazepam was stopped. Hospice and the primary care provider later noted that the resident’s agitation and confusion increased around the time clonazepam was discontinued and that the original plan had been to taper clonazepam gradually while adjusting lorazepam, rather than stopping clonazepam abruptly.

Interviews further documented that the administrative nurse told hospice and the resident’s DPOA that the resident could not be on both clonazepam and Ativan and indicated that if the DPOA did not agree, the resident could be taken home or the facility’s medical director would be used to discontinue medications. The DPOA reported feeling harassed, bullied, and pressured to have one of the medications discontinued, despite believing the combined regimen of lower‑dose Seroquel, clonazepam, and Ativan best controlled the resident’s behaviors and anxiety. The primary care provider confirmed she had intended to wean clonazepam over one to two weeks while adjusting Ativan but felt pressured by the situation at the facility to discontinue one of the medications sooner than planned. Facility administration later stated that the administrative nurse did not have authority to dictate what medications residents were allowed to take and that it would have been more appropriate to clarify concerns with the prescriber rather than stating the resident could not have the medication. The facility’s psychotropic medication policy stated that psychotropics are to be used only when a practitioner determines they are appropriate for a diagnosed condition and beneficial to the resident, with monitoring and documentation of response, underscoring that the resident’s ordered hospice comfort regimen was not followed as intended.