F0605

D

Failure to Justify and Monitor Psychotropic Medication Use

Bronx, New York Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from chemical restraints and unnecessary psychotropic medications, as required by regulation and facility policy. One resident with diagnoses including non-Alzheimer’s dementia, depression, and bipolar disorder received Seroquel and later Trazodone without adequate documentation of an appropriate diagnosis for the specific psychotropic use, without documented target behaviors to justify ongoing use, and without evidence of monitoring for effectiveness or side effects. The facility’s psychotropic medication policy required use in accordance with standards of practice and regulations to promote the resident’s highest practicable well-being, but the clinical record did not contain behavior monitoring or evaluation notes to support the continued administration of these medications.

The resident’s MDS assessment documented severe cognitive impairment, no indicators of psychosis, and no documented behavioral symptoms, while also noting that the resident was taking an antipsychotic with an indication, that no gradual dose reduction (GDR) had been attempted, and that the physician had not documented GDR as clinically contraindicated. Physician orders included Seroquel 125 mg at bedtime for dementia with behavioral disturbance, later increased to 150 mg at bedtime, and Trazodone 25 mg every 12 hours. Care plans for behavior, dementia, and psychoactive medications listed non-pharmacological interventions and required monitoring and documentation of behaviors, cognitive changes, and medication side effects and effectiveness. However, the monitoring/evaluation sections of these care plans lacked documentation of behavior escalation, target behaviors, or the effectiveness and side effects of the psychotropic medications, aside from a note about adding extra snacks.

Psychiatric consults documented diagnoses of major depressive disorder and dementia without behavioral disturbance, and noted that staff were to monitor mood and behavior and document accordingly, with follow-up every three months and as needed. Subsequent consults recorded that the resident was doing well and calm, leading to a dose reduction of Seroquel, and later that the resident was irritable with disorganized behaviors and poor sleep, prompting an increase in Seroquel and initiation of Trazodone. Despite these notes, there was no corresponding behavior documentation in the facility record to substantiate the reported behaviors or to show monitoring of medication response. Interviews with CNAs and an LPN indicated they did not observe aggressive behaviors, aside from occasional agitation and refusal of showers that could be managed with encouragement or additional assistance. The psychiatrist, medical director, and DON acknowledged issues such as incorrect or incomplete indications on orders, lack of staff behavior documentation, and reliance on hospital records and prior use of Seroquel, but there remained no documented evidence in the resident’s record of behaviors supporting ongoing psychotropic use or of systematic monitoring for effectiveness and side effects.

A family complaint further described concerns that the resident had never been diagnosed with bipolar disorder, was receiving psychotropic medications despite a dementia diagnosis, and that the family had not observed aggressive or violent behaviors during frequent visits. The family also reported that a community psychiatrist had not prescribed medication for behavior and that they were not informed when the facility started the resident on Seroquel. The complainant stated they had been asking the primary physician to stop certain medications due to increased risk in dementia and that the medications were not discontinued until they called 911 and had the resident transferred to the hospital and then to another nursing home. These documented concerns, combined with the lack of behavior monitoring, absence of clear diagnostic justification for the psychotropic regimen, and failure to document effectiveness and side effects, formed the basis for the cited deficiency related to unnecessary psychotropic medication use and chemical restraint.