Care Plans Lacked Non-Pharmacological Interventions for Psychotropic Medications: The facility failed to identify non-pharmacological interventions and targeted behaviors for psychotropic use in 4 sampled residents. A resident with depression and cognitive deficits, a resident with Alzheimer's disease, depression, and bipolar disorder, a resident with depression and CVA, and a resident with dementia, anxiety, depression, and psychotic disorder were all receiving antidepressant, antipsychotic, and/or antianxiety medications, but their care plans did not include the required non-pharmacological interventions or targeted behaviors. The DON stated that such interventions should be listed for antipsychotic and antidepressant medications.
A resident with dementia, anxiety, and depression received PRN alprazolam multiple times without documented targeted behaviors or documented non-pharmacological interventions before administration. The care plan did not identify specific behaviors for the antianxiety medication, the eMAR lacked behavior documentation tied to the doses, and the DON stated there was no documentation showing what the medication was treating. Staff described intermittent confusion and occasional anxiety, but the record did not show a psychotropic medication review in the EHR.
A resident with anxiety, depression, and moderate cognitive impairment continued receiving quetiapine after a physician ordered it discontinued. MAR review showed the antipsychotic was still administered across multiple months, and the DON acknowledged it should have been stopped when the order was signed.
Failure to document non-pharmacologic interventions for residents receiving psychotropic medications. Three residents with diagnoses including dementia, anxiety, depression, psychotic disorder, and PTSD had care plans and behavior monitoring records that did not identify or consistently document nonpharmacological approaches before PRN or other psychotropic use. Staff interviews showed inconsistent understanding of the interventions being used, while the DON stated staff should have implemented and documented them.
Failure to attempt a GDR for a resident receiving lorazepam for anxiety. The resident had intact cognition, diagnoses of anxiety and depression, and an active order for lorazepam at bedtime with no discontinue date. The record showed no GDR since the prior dose reduction, and the annual psychotropic review documented that a GDR was not contraindicated. The DON acknowledged the facility missed the medication on the quarterly psychotropic review and had not attempted or discussed a GDR since 2024.
PRN Lorazepam was continued for a resident with moderate cognitive impairment, dementia, CVA, anxiety, and adult failure to thrive without documentation of a physician rationale to extend the order beyond 14 days. The resident’s chart showed the medication was used multiple times for agitation, anxiety, and restlessness, and an LPN reported it was minimally effective unless given early; the Facility Administrator confirmed the required rationale was not documented.
Failure to Include Psychotropic Care Plan Interventions: The facility did not identify individualized behaviors or non-pharmacological interventions for 5 sampled residents receiving psychotropic medications. Residents receiving antipsychotic, antianxiety, antidepressant, and hypnotic medications had care plans that lacked targeted behaviors and non-pharmacological interventions, including residents with intact cognition and residents with dementia, depression, and behavioral disturbance. The MDS coordinator and DON acknowledged the missing care plan content.
Failure to Document Non-Pharmacological Interventions Before PRN Antipsychotic Use: A resident with severe cognitive loss, dementia, depression, and anxiety received PRN Haloperidol for agitation and irritability on multiple occasions, but the MAR, progress notes, and supplemental documentation did not show nonpharmacological interventions tried before administration. Staff and the DON confirmed the chart lacked the required documentation, and the facility policy stated antipsychotics should not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions.
A resident with a BIMS of 13 and diagnoses including non-Alzheimer’s dementia, anxiety, and depression was receiving Seroquel for agitation and anxiety despite no documented hallucinations, delusions, or behavioral symptoms on MDS review. The chart showed no completed GDR for the antipsychotic, the care plan lacked specific non-pharmacological interventions, and the DON and Medical Director both stated the resident was no longer exhibiting the behaviors that had prompted the medication.
The facility failed to ensure GDRs were completed or clinically justified for residents receiving psychotropic medications. One resident with anxiety disorder and cognitive impairment remained on Buspirone, Melatonin, and Olanzapine without a documented rationale for why GDR was contraindicated, and another resident with anxiety disorder, bipolar disorder, and PTSD remained on multiple psychotropics, including antipsychotics, antidepressant, and anticonvulsant therapy, without a documented rationale for no GDR after the pharmacist requested review.
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