F0757

D

Inaccurate Indication for Antipsychotic Medication

Alice, Texas Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs by not having an adequate, accurate indication for the use of the antipsychotic medication risperidone prior to administration. The resident was an older female with anxiety disorder, major depressive disorder, and dementia with behavioral disturbance, admitted with an initial admission date in 2022 and a later admit date in 2026. Her quarterly MDS showed a BIMS score of 12, indicating moderately impaired cognition, and documented use of antipsychotic and antidepressant medications, but did not indicate behaviors. The resident’s quarterly care plan identified a problem of antipsychotic use, listing risperidone 0.5 mg at bedtime related to dementia, and a separate problem of calling/yelling out for help related to unspecified dementia with behavioral disturbances, with interventions including monitoring, redirection, documentation of behaviors, and medication administration as ordered.

Record review showed an active order for risperidone 0.5 mg at bedtime with the indication of unspecified dementia with other behavioral disturbance, with an order and start date in late February 2026. Interviews with staff revealed inconsistent understanding and documentation of the indication for this antipsychotic. An LVN stated that if a psychiatrist ordered an antipsychotic with an indication of dementia, she would ensure the order also indicated it was for behaviors, and she would consult the DON if she had questions, but she could not state the negative outcome of having an antipsychotic order with an indication of dementia. The ADON stated it was her responsibility to ensure all antipsychotic orders had the correct indication and believed the risperidone order with an indication of dementia was correct because that was how the physician had written it, while also acknowledging that a gradual dose reduction had been initiated because the resident did not have a diagnosis that fit that medication.

Further interviews clarified that the documented indication on the order did not match the prescriber’s intent or the resident’s psychiatric diagnosis. The pharmacist stated the order did not have the correct indication and reported initiating a gradual dose reduction, explaining that the resident had behavioral issues due to schizoaffective disorder. The psychiatric NP reported he had ordered risperidone with an indication of schizoaffective disorder and stated he would never prescribe an antipsychotic with an indication of dementia, attributing the incorrect indication to an error when the phone order was entered. The DON confirmed that the risperidone order did not have the correct indication and explained that the resident had a diagnosis of schizoaffective disorder prior to readmission, which must have been struck out at readmission. The facility’s own policy on psychotropic medications required an adequate, documented clinical rationale and use only for a specific, diagnosed, and documented condition, which was not met in this case due to the incorrect and inadequate indication documented for risperidone.