F0605

D

Failure to Assess, Care Plan, and Justify Antipsychotic Use for a Dementia Resident

Hermitage, Missouri Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete a comprehensive assessment and establish a care plan before initiating and escalating psychotropic and antipsychotic medications for a resident with dementia. The resident was admitted with diagnoses including dementia, anxiety, and cerebral infarction, and the hospital discharge summary showed no antipsychotic, antianxiety, or antidepressant medications at discharge. The admission physician note documented the resident as alert, oriented to self, pleasant, conversant, and following commands, with no documentation of a need for or orders for antipsychotic medications. The quarterly MDS indicated severe cognitive impairment, behavioral symptoms directed and not directed toward others one to three days a week, and that the resident received antipsychotic medication, but the facility did not provide a comprehensive care plan for the resident.

On the evening of admission, nursing staff documented that the resident attempted to ambulate without assistance, did not accept redirection, and was brought to the nurses’ desk for closer monitoring. After the resident refused and spit out melatonin ordered by the NP, staff obtained an order for and administered a 2.5 mg IM haloperidol injection for a diagnosis of dementia, without documentation of a clinical rationale consistent with psychosis or serious harm. Over the following days, staff obtained multiple new and escalating psychotropic and antipsychotic orders, including PRN and then scheduled risperidone, lorazepam four times daily and then PRN, Zoloft, additional IM haloperidol orders (both lactate and decanoate), and later Seroquel, often for behaviors such as crawling on the floor, anxiety, yelling out, restlessness, roaming, and standing up from the wheelchair. The POS frequently listed diagnoses such as dementia without behavioral, psychotic, mood disturbance, and anxiety, or mild dementia with psychotic disturbance, while the record lacked corresponding comprehensive assessments or clear clinical justification for these medication regimens.

Throughout this period, the facility failed to consistently monitor, document, and address the resident’s behaviors using nonpharmacological interventions. MAR entries often listed general reasons such as anxiety, yelling, roaming, restlessness, or aggression for PRN antipsychotic and antianxiety administration, but nursing progress notes on multiple dates did not describe the specific behaviors at the time of administration or any nonpharmacological approaches attempted. There was also missing documentation regarding receipt and discontinuation of lorazepam and new antipsychotic orders, and no separate behavior monitoring records or antipsychotic assessments were provided for the month. Interviews with an RN, the DON, the NP, the physician, and the Administrator confirmed that standing up from a wheelchair or similar behaviors were not appropriate indications for antipsychotic use, that risperidone dosing had been increased excessively, that IM haloperidol at the dose given was not appropriate, and that nonpharmacological interventions should have been tried first. The facility’s own policies required residents to be free from chemical restraints and required comprehensive, interdisciplinary care planning based on thorough assessment, but these processes were not followed for this resident.

The facility also failed to develop and implement a care plan specifically addressing the use of antipsychotic medications for this resident. Despite repeated behavioral episodes documented in nursing notes—such as attempts to walk unassisted, sliding from the wheelchair, increased confusion, throwing items, yelling, cursing, spitting out medications, grabbing other residents, and multiple falls—there was no evidence of a comprehensive, individualized care plan that incorporated measurable goals, time frames, and nonpharmacological strategies to manage the resident’s dementia-related behaviors. The record did not show an interdisciplinary approach or revisions to a care plan in response to changes in the resident’s condition and medication regimen. Instead, the response to behaviors was largely pharmacologic, with frequent additions and changes to antipsychotic and antianxiety medications without the required assessment, documentation, and care planning to support their use.