Incomplete Psychotropic Monitoring Documentation: The facility did not complete or accurately document monthly behavior summaries for a resident receiving Ativan, quetiapine, risperidone, and sertraline, and another resident’s behavior summary for lurasidone HCl and fluoxetine HCl was inaccurate compared with the MAR. The same resident also lacked complete orthostatic BP monitoring documentation, as the required sitting readings were not recorded within the appropriate time frame. The SSD and DON verified the missing and incorrect documentation.
A resident with Parkinson’s disease, bipolar disorder, dementia, depression, and anxiety was started on multiple psychotropic meds, including mirtazapine, quetiapine, lorazepam, and divalproex, without documented ICO and without documented NPIs before use. Nursing and RT notes later showed the resident became progressively drowsy and difficult to arouse, but the MD was not informed of the full change in condition until the RP insisted on 9-1-1 transfer. The resident was sent to the hospital and admitted to the ICU with AMS, benzodiazepine intoxication, and hypoglycemia.
A resident received Seroquel for psychosis/behavioral symptoms even though staff stated the resident was not a danger to self or others, behaviors were not interfering with ADLs, and no NPI were documented before administration; the chart also showed no GDR. Another resident had a PRN Xanax order for anxiety that lacked a stop date, and facility staff confirmed the order did not include an end date despite policy requiring a defined duration for PRN psychotropic meds.
Inadequate assessment and monitoring before lorazepam orders: A resident with anxiety and impaired decision-making capacity received PRN lorazepam without a documented pre-order assessment, target behavior, or explanation for the order. The record also showed combative and striking-out behaviors, but the LNs did not document monitoring or evaluation before a routine lorazepam order was obtained for anxiety manifested by striking out, and the eMAR lacked target-behavior documentation for administered doses.
A resident was given two atypical antipsychotics plus an anxiolytic without documented GDR attempts, measurable behavior goals, or reliable side effect monitoring, and another resident had Risperdal and lorazepam without documented NPI use or GDRs. Additional residents had an Amitriptyline order with an inappropriate indication and sertraline without documented NPI monitoring. Staff and the DON/PA stated the records lacked needed documentation for indications, monitoring, and psychotropic management.
A resident with Alzheimer’s disease and bipolar disorder was prescribed clonazepam daily and PRN for anxiety manifested by agitation, but nursing staff monitored only for the broad behavior of agitation and not for the resident’s specific behaviors, including demanding behavior and verbalizing a desire to elope. Staff stated the PRN order and behavior monitoring were not specific enough to ensure the medication was given and tracked for the appropriate behaviors.
Inaccurate behavior monitoring for psychotropic medication use. A resident with dementia, depression, schizophrenia, and bipolar disorder was receiving olanzapine and divalproex sodium, but the EMAR behavior logs were not specific and did not accurately capture the resident’s targeted behaviors. An RN stated the documentation used check marks and zero counts that did not reflect the resident’s actual physical and verbal aggression, including a resident-to-resident altercation, and the MDS nurse stated monthly totals and psychiatric follow-up were not documented.
Unnecessary psychotropic medication use was identified for a resident with psychosis, MDD, and bipolar disorder who was ordered Seroquel for mood disorder manifested by agitation and restlessness affecting sleep. The order did not include monitoring of sleep hours to assess effectiveness, and the DON stated agitation and restlessness were not specific indications or target behaviors for Seroquel. Facility policy stated antipsychotics should not be used when the only symptoms are restlessness, insomnia, or similar nonspecific behaviors, and psychotropic therapy should be evaluated with specific behavior monitored every shift.
Incomplete informed consent for psychotropic medications: Five residents had antidepressant orders tied to depression, withdrawn behavior, sadness, or sleep issues, but the psychotherapeutic drug consent forms did not include the reason for use or the benefits. The QAN and DON stated licensed staff should verify that the consents were complete, and the facility policy required psychotropic drugs to be used only when medically necessary with informed consent verified by the LPN.
PRN Psychotropic Medication Given Without Adequate Documentation: A resident with CVA-related aphasia, severe cognitive impairment, and inability to verbalize needs had PRN lorazepam ordered for anxiety manifested by excessive restlessness, but the DON found behavior episodes and doses given without documentation of the behavior, triggers, nonpharmacological interventions, or the reason for administration. Psychiatric notes also lacked medical history, and there was no documentation showing the resident’s baseline restlessness, paranoia, or other underlying causes were considered.
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