Unordered Antipsychotic Administered for Agitation: A resident with intact cognition and behavioral symptoms received haloperidol cream for agitation during a behavioral episode even though the EMAR lacked an active PRN order at the time of administration. Staff statements and the DON confirmed the medication was given without physician authorization and was considered a chemical restraint. The care plan did not address antipsychotic use, and the facility policy required psychotropic medications to be used only when medically necessary and documented by a practitioner.
Psychotropic medication management deficiencies were identified for multiple residents. The facility lacked GDR documentation for residents receiving antipsychotic, antianxiety, and antidepressant medications, did not document non-pharmacological interventions before PRN quetiapine was given, and had a PRN psychotropic order that exceeded the 14-day limit without physician review. Residents involved had severe cognitive impairment and diagnoses including anxiety, depression, dementia, and delirium.
A resident received PRN Lorazepam for agitation multiple times over several months, but the MAR supplemental documentation and progress notes did not show any nonpharmacological interventions tried before the medication was administered. The DON stated she could not find proof that interventions were attempted, and the facility policy required psychotropic meds to be used only after non-pharmacological interventions were unsuccessful.
A resident with intact cognition and diagnoses including depression, anxiety, and insomnia asked to get out of bed into his wheelchair because he was in pain and anxious, but an LPN told him to take PRN hydroxyzine first instead of using non-pharmacological measures. The resident received the medication, later experienced hypersomnolence and grogginess, and staff acknowledged the non-pharmacological interventions in the care plan were not used first.
Failure to document non-pharmacologic interventions and limit PRN psychotropic orders: A resident with severe cognitive impairment received PRN lorazepam for agitation without documentation of three attempted non-drug interventions, and two residents with dementia had PRN Ativan/lorazepam orders extended beyond 14 days without the required rationale documented by the physician. The care plans listed general psychotropic protocols, but specific interventions were not documented for the affected residents, and requested PRN psychotropic reviews were not produced during the survey.
Failure to Document Behavior Triggers and Non-Pharmacologic Interventions for Psychotropic Medication Use The facility failed to consistently document resident-specific behaviors and attempted non-pharmacologic interventions for 3 residents receiving psychotropic meds. Records showed psychotropic orders for anxiety, depression, and psychosis-related symptoms, but the consent forms, care plans, progress notes, and TARs often did not identify the target behaviors or the non-pharmacologic alternatives attempted. One resident had intact cognition and orders for an antianxiety med and an antidepressant; another had severe cognitive impairment and multiple psychotropic orders; and a third had intact cognition with anxiety and PRN antianxiety use. Staff interviews showed some awareness that target behaviors and interventions should be documented, but the required behavior details were not consistently recorded.
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.
A resident with moderate cognitive impairment, dementia, and depression was receiving Sertraline, but the EHR lacked documentation of a GDR attempt or a rationale for not attempting one. The contracted pharmacist recommended a GDR in the MRR, yet the PCP response was not documented, and the DON acknowledged she did not follow through after emailing the PCP twice without a reply. The facility policy required GDRs for residents on psychotropic meds unless clinically contraindicated.
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