A resident with anxiety and depression was prescribed Buspirone for anxiety as manifested by restlessness/inability to relax, but the order did not identify the resident’s specific behaviors. Staff described the resident’s restlessness differently, the CNA did not know the signs and symptoms, and the RN noted the MAR did not reflect the resident’s anxiety level. The DON stated the documentation was not accurate because staff had different ideas of what restlessness meant, and the facility policy required psychotropic use only for a specific, diagnosed, and documented condition.
A resident with dementia, behavioral disturbances, and depression was ordered quetiapine PRN for psychosis and trazodone PRN for insomnia without a stop date, and the informed consent was signed after the orders were already entered and sent to the pharmacy. The RN and DON stated consent should have been obtained before ordering the psychotropic medications, and the facility policy required written informed consent and limited PRN psychoactive medications to 14 days.
Antipsychotic Medication Given Without Confirmed Diagnosis: A resident with dementia and depression became verbally aggressive toward a CNA during care and was ordered Haldol and Seroquel for combative behavior. RN and LVN interviews indicated the resident was redirectable and that the Seroquel order did not identify a medical diagnosis for the behavior. NP stated the medication was ordered to manage aggression, while the DON noted antipsychotics require an indication and that the cause of the behavior should be determined.
Unnecessary Psychotropic Medication Use Without Documented GDR Rationale: A resident with depression remained on Zoloft 50 mg daily even though MDS assessments showed no depressive symptoms and the MAR reflected almost no documented behaviors. The DON acknowledged the resident’s care plan goals had been met, but the psych note did not provide a specific clinical rationale for continuing the antidepressant at the original dose or a documented contraindication to GDR, despite facility policy requiring GDR attempts or clear clinical justification.
The facility failed to monitor the specific target behaviors for two residents receiving psychotropic medications. One resident on quetiapine for schizophrenia had no order to monitor visual hallucinations, and another resident on trazodone for depression had no order to monitor hours of sleep. Staff stated the missing monitoring was needed to assess medication effectiveness, and the DON confirmed the facility policy required documentation of target behaviors and monitoring for efficacy.
A resident with encephalopathy, CVA, cognitive communication deficit, MDD, severe dementia with behavioral disturbance, and insomnia was prescribed lorazepam 1 mg PRN for anxiety/irritability for 90 days. An LN contacted the physician by text to restart the medication, and the physician approved the extended PRN order without a documented rationale. The MAR showed the medication was administered at least once daily on multiple days, and the facility policy required PRN psychoactive meds to be limited to 14 days unless continued use was documented.
A resident with schizophrenia and severe cognitive impairment received Zyprexa for psychotic symptoms and Remeron for right hand tremors, but staff could not show that non-pharmacologic interventions were provided before the psychotropic medications were given. The LVN also stated there was no documentation that the resident’s hand tremors were being monitored, and the DON noted that behavior monitoring should be documented so the psychiatrist can review whether the medications should continue.
A resident with depression, RA, and obesity was prescribed fluoxetine for statements of hopelessness, and staff monitored depression behavior and medication side effects each shift. However, the care plan listed the psychotropic medication and a behavior goal but did not include non-pharmacological interventions, despite facility policy calling for individualized nondrug and pharmaceutical interventions.
Three residents received PRN lorazepam without proper behavior documentation or clinical indication. One resident was given multiple doses despite zero documented anxiety behaviors, another had doses that did not match the limited anxiety episodes recorded, and a third received doses with no behavior monitoring documented in the MAR. RN and DON interviews confirmed the mismatches and lack of monitoring.
A resident with orders for PRN Alprazolam for anxiety was not given adequate monitoring for anxiety symptoms or verbalizations of nervousness/anxiousness. RN and DON both stated there was no physician order to monitor those symptoms, and the resident reported feeling anxious, especially when people bothered him at night.
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