F0605

E

Psychotropic Medication Use Without Documented Insomnia Diagnosis

Artesia, New Mexico Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to the use of psychotropic medications without documented medical necessity for two residents. For one resident with diagnoses including ESRD, adult failure to thrive, anxiety disorder, depression, and opioid dependence, record review showed a physician’s order dated 07/09/25 for melatonin 5 mg by mouth once daily for insomnia. During interview, the DON confirmed that the stated indication for the melatonin was insomnia, but the resident did not have an insomnia diagnosis in the clinical record. The DON further confirmed that medications should be documented to treat specific conditions as diagnosed, and this was not done for this resident.

For a second resident with multiple diagnoses including schizophrenia, bipolar disorder, bacteremia, syphilis, MDR pseudomonas infection, third-degree burn of the left lower limb, cannabis use, stimulant use, and psychoactive substance use, record review showed a physician’s order dated 02/17/26 for melatonin 5 mg by mouth at bedtime for insomnia. In interview, the DON confirmed that the indication for melatonin was insomnia, but this resident also did not have an insomnia diagnosis documented in the record. The DON again acknowledged that medications should be documented to treat specific diagnosed conditions and that this requirement was not met, resulting in psychotropic medication use without corresponding documented diagnoses for both residents.