F0605

D

Inadequate Indications for Antipsychotic Use and Chemical Restraint Concerns

Mcallen, Texas Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from chemical restraints and unnecessary psychotropic medications, specifically antipsychotics with black box warnings, for two residents reviewed. For one resident with dementia, Alzheimer’s disease, hypertension, and Type 2 diabetes, the facility administered Lurasidone 40 mg daily based on a physician order that cited “unspecified psychosis not due to a substance or known physiological condition (F29)” as the indication. The resident’s care plan documented use of antipsychotic medications for mood disorder and psychosis and included monitoring for adverse reactions and black box warnings, but the record did not show an adequate indication for the use of Lurasidone in the context of dementia-related psychosis. The medication was administered routinely over several days as reflected on the MAR.

For another resident with early-onset Alzheimer’s disease, heart disease, Type 2 diabetes, hypertension, bipolar disorder with psychotic features, intermittent explosive disorder, mood disorder due to a known physiological condition, and unspecified intellectual disabilities, the facility administered two antipsychotics—Haldol Decanoate and Seroquel—without an adequate indication documented in relation to dementia. The care plan identified the use of Seroquel and Haldol for psychosis with targeted behaviors of agitation, yelling, and grabbing at others. Physician orders directed monthly intramuscular injections of Haldol Decanoate 50 mg and oral Seroquel 300 mg tablets, initially two tablets at bedtime and later one tablet daily in the morning, all tied to a diagnosis of unspecified psychosis (F29). MARs showed consistent administration of these medications over multiple months. The orders and associated black box warnings noted increased mortality in elderly patients with dementia-related psychosis, yet the indication remained psychosis in residents with dementia diagnoses.

Interviews with facility staff and prescribers further illustrated the circumstances leading to the deficiency. A mental health nurse practitioner stated that psychosis was a proper diagnosis for many dementia residents and asserted that more than half of dementia residents in nursing homes are psychotic and need antipsychotics, expressing disagreement with CMS concerns about antipsychotic use and black box warnings. An LVN reported that staff called the provider for behaviors such as crawling on the floor, yelling, aggression, or agitation, and that the provider would order medication; he acknowledged sometimes needing to ask for the indication and stated he did not know that psychosis was not an appropriate indication for an antipsychotic in residents with dementia or Alzheimer’s, adding that nurses followed provider orders as long as consents were signed. The DON confirmed there were numerous active antipsychotic orders, acknowledged that psychosis was not an appropriate indication for antipsychotic use in residents with Alzheimer’s or dementia, and stated that when a doctor or NP wrote an order, staff could not refuse to give the medication even if the indication was inappropriate. The facility’s own psychotropic drug use policy required that psychotropics be used only to treat specific, diagnosed, and documented conditions and not as chemical restraints, underscoring the discrepancy between policy and practice in these cases.

The facility’s policy on psychotropic drug use defined chemical restraint as any drug used for discipline or staff convenience and not required to treat medical symptoms, and emphasized that psychotropic medications should only be used when nonpharmacological interventions are clinically contraindicated and when a practitioner determines the medication is appropriate for a specific, diagnosed, and documented condition. Despite this, the records for the two residents showed routine administration of antipsychotics with black box warnings based on indications of unspecified psychosis in the presence of dementia diagnoses, without adequate documentation that the medications were necessary to treat clearly defined medical symptoms as required by the policy. This mismatch between documented indications, resident diagnoses, and policy requirements formed the basis of the cited deficiency.