Failure to Follow Up on Recommended GDR for Antipsychotic Medication
Summary
The facility failed to follow up on a psychiatrist’s recommendation for a gradual dose reduction (GDR) of quetiapine for one resident who was receiving antipsychotic medication. The resident had diagnoses including major depressive disorder, PTSD, and paranoid schizophrenia, and the quarterly MDS dated 1/16/2026 showed a BIMS score of 00 out of 15, indicating cognition could not be assessed. The resident was observed sitting in a reclining area in the hallway near the nursing station and had a splint on the left hand/wrist. The psychiatric progress note dated 1/5/2026 documented an assessment/plan recommending discontinuation of the current Seroquel order and starting Seroquel 25 mg at bedtime for 7 days, then discontinuing it, with the note stating that a dose reduction was recommended. The note also stated that recommendations were discussed with facility staff, who would await approval from the PCP and then obtain consent from the appropriate decision-maker. The physician order summary showed quetiapine 50 mg at bedtime for schizophrenia, with the order dated 10/8/2025 and a discontinue date of 2/2/2026. The January and February 2026 MARs showed the quetiapine order was administered as ordered from 1/6/2026 through 2/2/2026. Review of the progress notes did not show documentation that the GDR was addressed by the PCP or the resident representative, and the same GDR recommendation appeared again in the psychiatric progress note dated 2/3/2026. The consultant pharmacist’s monthly report dated 1/13/2026 also noted the psych consult recommendation for GDR and requested follow-up documentation. Facility staff, including the RN/UM and DON, acknowledged during interview that they would expect documentation showing the recommendation was addressed, but no such documentation was present in the record reviewed.
Penalty
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Surveyors found that the facility failed to identify and monitor target behaviors for two cognitively intact residents receiving antipsychotic medications. One resident with psychotic and mood-related diagnoses was given Abilify at bedtime for psychotic disorder with hallucinations, and another resident with Wernicke’s encephalopathy, alcohol abuse, psychotic disorder with hallucinations, and dementia was given Zyprexa at bedtime. In both cases, medical record reviews showed no documented target behaviors or behavior monitoring related to the antipsychotic use, and the ADON and DON each confirmed that staff had not established or tracked target behaviors for these medications.
Failure to monitor psychotropic medication side effects for two residents. One resident with PTSD and insomnia had orders for Ativan PRN and mirtazapine, and another resident with schizoaffective disorder and a history of TBI had orders for divalproex and mirtazapine. Both residents were cognitively intact, but their care plans did not direct monitoring for psychotropic side effects, and no active physician orders were in place for that monitoring; the DON verified the monitoring was not completed.
Failure to monitor psychotropic medication effectiveness and side effects affected three residents receiving psychotropic meds. One resident with psychosis, mood disorder, anxiety, and dementia had orders for escitalopram, olanzapine, and mirtazapine, but no documented monitoring. Another resident with dementia, hallucinations, anxiety, restlessness, and agitation received PRN clonazepam six times with no evidence of monitoring. A third resident with dementia, Lewy body neurocognitive disorder, PTSD, and depression had orders for mirtazapine and clozapine, but the record showed no monitoring for adverse reactions, EPS, tardive dyskinesia, suicidal ideation, or unusual behavior.
Failure to monitor residents on psychotropic medications. Three residents receiving psychotropic meds were not monitored for behaviors or medication side effects. One resident with bipolar disorder and anxiety received clonazepam, another resident with depression received sertraline, and a third resident with dementia and depression received aripiprazole and Lexapro. The RNCC confirmed no behavior monitoring was in place to assess efficacy and/or side effects.
Unjustified psychotropic medication use was identified for a resident receiving Olanzapine for schizophrenia despite no schizophrenia diagnosis in the record. The MDS and PASRR also did not show schizophrenia, and the DON confirmed the resident was receiving the medication without that diagnosis documented. The Administrator stated the diagnosis had been identified after a behavioral health hospital stay, but hospital paperwork confirmed there was no schizophrenia diagnosis.
A resident with dementia and intact cognition was given a one-time dose of Haldol by an LPN after an attempt to hit staff during a dressing change, despite no documented behaviors or justification in the medical record. Facility policy required antipsychotic use only for specific conditions and after other interventions, but there was no evidence of imminent danger or proper documentation to support the administration.
Failure to Monitor Target Behaviors for Residents on Antipsychotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to identify and monitor target behaviors for residents receiving antipsychotic medications, as required for appropriate use and monitoring of psychotropic drugs. For one resident admitted with diagnoses including acute kidney failure, psychotic disorder, anxiety disorder, and bipolar disorder, the physician ordered Abilify 10 mg by mouth at bedtime for psychotic disorder with hallucinations. The resident’s MDS assessment indicated the resident was cognitively intact and received antipsychotic medication. However, review of the medical record showed no documentation of target behaviors or behavior monitoring related to the administration of Abilify. In an interview, the Assistant Director of Nursing confirmed that staff had not identified or monitored target behaviors associated with this antipsychotic use. A second resident, admitted with diagnoses including Wernicke’s encephalopathy, alcohol abuse, psychotic disorder with hallucinations, and dementia, had a physician’s order for Zyprexa 7.5 mg by mouth at bedtime related to Wernicke’s encephalopathy. The MDS assessment for this resident also showed that the resident was cognitively intact and received antipsychotic medication. Review of this resident’s medical record likewise revealed no documentation of target behaviors or monitoring of behaviors related to the administration of Zyprexa. In an interview, the Director of Nursing confirmed that facility staff had not identified or monitored target behaviors for this resident’s antipsychotic medication.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #6 on 03/26/2026. It was determined that there were no negative effects related to the lack of behavioral monitoring identified during Annual Survey. LNHA notified Resident #6's primary care provider on 03/26/2026, of findings noted during Annual Survey and that no negative effects were identified during head-to-toe assessment/observation. Primary care provider acknowledged the missing behavioral documentation and that there were no negative effects related to the lack of behavioral monitoring. No new orders received from primary care provider. DON completed a head-to-toe physical assessment/observation on Resident #20 on 03/26/2026. It was determined that there were no negative effects related to the lack of behavioral monitoring identified during Annual Survey. LNHA notified Resident #20's primary care provider on 03/26/2026 of findings noted during Annual Survey and that no negative effects were identified during head-to-toe assessment/observation. Primary care provider acknowledged the missing targeted behavioral documentation and that there were no negative effects related to the lack of behavioral monitoring. No new orders received from primary care provider. On or before 04/30/2026, DON/Designee will review other residents' diagnosis list. Any resident with a mental health diagnosis, will have a medication review completed to ensure that targeted behavioral observations are added to treatment administration record (TAR) so that nurses will review/document any specific experienced behaviors on their shift accordingly. On or before 04/30/2026, DON/Designee will educate licensed nursing personnel of the following: 483.10(e)(1),483.12(a)(2),483.45(c)(3)(d)(e) Right to be Free from Chemical Restraints §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any . . . chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from . . . chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. §483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (d)(5) of this section. §483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Additionally, licensed nursing personnel will be educated on policy review / adjustment as well as expectations for monitoring targeted behavior as noted in the following paragraph: On or before 04/30/2026, LNHA/Designee will review facility's policy & procedure regarding targeted behavioral monitoring. During this review, IDT will ensure that all residents with mental health, intellectual diagnoses or who are taking antipsychotic medications have specific targeted behavioral monitoring tasks placed/implemented, so that licensed nursing personnel are documenting behaviors or lack of behaviors that occur during their shift. This will include every shift documentation by licensed nursing personnel. DON/Designee will complete an audit of 5 residents' medical records weekly x4; then as determined by QAA. This audit will include the patient's identifier (facility's patient identifier), any behaviors were indicated and documented (will also reflect if no behaviors occurred), interventions to any behaviors that were documented. New procedure will include behavioral monitoring for those who suffer from mental health/intellectual disabilities and also those who do not.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects for two residents reviewed for unnecessary medications. One resident had diagnoses including unspecified head injury, PTSD, and psychophysiologic insomnia, was cognitively intact with a BIMS score of 15, and had care plan interventions focused on anxiety, environmental stimulation, reassurance, and psychiatric referral. The resident’s medication orders included Ativan 0.5 mg twice daily as needed for anxiety and mirtazapine 7.5 mg at bedtime for sleep, but there were no physician orders initiated to monitor psychotropic medication side effects, and the care plan did not direct monitoring for those effects. The second resident had diagnoses including aphasia, hemiplegia and hemiparesis following cerebral infarction, schizoaffective disorder, and a history of traumatic brain injury. The resident’s quarterly MDS showed a BIMS score of 15, with depression noted during the look-back period and no behaviors at the time of assessment, while the care plan identified risks for behavior symptoms and mood changes related to depression, bipolar disorder, and antidepressant and antipsychotic medications. Medication orders included divalproex sodium 125 mg twice daily and mirtazapine 7.5 mg at bedtime, but there were no orders entered to monitor psychotropic medication side effects. The DON stated the facility used a house order for monitoring side effects, that the order was not active for these residents, and later verified that monitoring for psychotropic medication side effects had not been completed.
Failure to Monitor Psychotropic Medication Effects and Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects for three residents reviewed for unnecessary medications. Resident #15, admitted with psychosis, mood disorder, anxiety, frontotemporal neurocognitive disorder, and dementia, had orders for escitalopram, olanzapine, and mirtazapine, and the care plan directed staff to monitor for side effects and effectiveness every shift, but the record contained no orders or documentation showing monitoring for effectiveness, adverse effects, or side effects from 02/01/26 through 03/09/26. The DON verified there was no documentation that Resident #15 was monitored for adverse effects or side effects of the psychotropic medications. Resident #35, admitted with dementia, hallucinations, anxiety, restlessness, and agitation, had a PRN clonazepam order for agitation that was administered six times in February, but the record showed no documentation of monitoring for potential side effects or effectiveness. Resident #10, admitted with dementia, type II diabetes mellitus, lumbar vertebra fracture, neurocognitive disorder with Lewy bodies, hypertension, PTSD, depression, transient ischemic attack, and cerebral infarction, had orders for mirtazapine and clozapine, and the care plan included monitoring for adverse reactions such as tardive dyskinesia, EPS, suicidal ideations, and unusual behavior symptoms; however, the medical record contained no evidence that these psychotropic medications were monitored for side effects or adverse reactions. The DON verified the lack of documentation for monitoring in Resident #10's record, and the facility policy stated that psychotropic medication use would be monitored for efficacy, side effects, and adverse consequences.
Failure to Monitor Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents prescribed psychotropic medications were monitored for behaviors and medication side effects. This affected three residents reviewed for psychotropic medication use out of a census of 60. Resident #1 was admitted with diagnoses including congestive heart failure, bipolar disorder, parkinsonism, type II diabetes mellitus, and anxiety, had intact cognition on the annual MDS, and was ordered clonazepam 1 mg twice daily for anxiety. Resident #1’s care plan identified a mood problem related to anxiety, depression, and bipolar disorder and included monitoring and documenting side effects and effectiveness of medications. Resident #48 was admitted with diagnoses including depression, type II diabetes mellitus, heart disease, and peripheral vascular disease, had intact cognition on the quarterly MDS, and was ordered sertraline Hcl 25 mg daily for depression. Resident #66 was admitted with diagnoses including pelvic fractures, cerebral infarction, dementia, bariatric surgery, and Raynaud’s syndrome, was alert and oriented on admission, and had a baseline care plan stating medications and side effects should be monitored. Resident #66 was ordered aripiprazole 10 mg daily for depression and Lexapro 20 mg daily for antidepressant use. During interview and concurrent record review, the RNCC confirmed there was no behavior monitoring in place to monitor for efficacy and/or side effects of the psychotropic medications for Residents #1, #48, and #66.
Unjustified Psychotropic Medication Use Without Documented Diagnosis
Penalty
Summary
The facility failed to have a justified diagnosis for the use of a psychiatric medication for one resident, Resident #55, who was reviewed for unnecessary medication. The resident was admitted with diagnoses including anxiety, insomnia, major depressive disorder, unspecified dementia, and unspecified mood affective disorder. On review of physician orders, the resident was receiving Olanzapine 5 mg at bedtime and Olanzapine 2.6 mg daily, both ordered for schizophrenia. Review of the annual MDS showed a BIMS score of 9 and no diagnosis of schizophrenia in Section I. The PASRR also showed no diagnosis of schizophrenia. The DON confirmed the resident did not have schizophrenia in the record but was receiving medication for it. The Administrator stated schizophrenia had been identified after a behavioral health hospital stay, but the paperwork obtained from that hospital confirmed there was no diagnosis of schizophrenia. The facility's Psychotropic Medication Management Policy stated an unnecessary drug is one used without adequate indications for use and that when psychotropic medications are ordered or increased, a specific diagnosis must be documented in the medical record.
Failure to Prevent Unnecessary Use of Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cerebral infarction, glaucoma, anxiety disorder, and vascular dementia was administered an antipsychotic medication (Haldol) without proper documentation or justification. The resident, who had intact cognition and required assistance with transfers, had no routine psychoactive medication orders. After returning from the hospital, the resident exhibited agitation and combative behavior, leading to a one-time order for Haldol and Ativan if needed for agitation and aggression. However, the medications were not administered at that time, and the resident later rested calmly. Over 24 hours later, an LPN administered Haldol to the resident after the resident attempted to hit the nurse during a dressing change. There was no documentation in the progress notes to indicate the reason for administering the medication at that time, and behavior tracking did not show any documented behaviors warranting its use. Facility policy required that antipsychotic medications only be used for specific conditions and after other causes of behavioral symptoms had been addressed. The Acting DON confirmed there was no evidence of imminent danger to self or others to justify the use of Haldol, and the only incident noted was the resident pulling a fire alarm earlier, with no further documentation.
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