A resident with Alzheimer’s disease, severe cognitive impairment, anxiety, mood disorder, and repeated falls received multiple psychotropics for agitation, sleep disturbance, and behavioral symptoms, including lorazepam, trazodone, risperidone, quetiapine, divalproex, and mirtazapine. Staff notes and interviews described wandering, impulsivity, agitation, and intermittent combativeness, but the record did not document individualized nonpharmacological interventions before PRN lorazepam was given, and some medication orders were entered by an LPN with unclear provider confirmation. The resident also received PRN lorazepam too close to scheduled bedtime doses despite order restrictions, and later sustained a fall with bruising and a subdural hemorrhage.
The facility failed to document nonpharmacologic interventions before giving psychotropic meds to three residents and failed to complete GDRs for two residents. One resident with dementia received Seroquel and PRN Hydroxyzine without a documented behavior plan or personalized interventions, another resident received PRN Ativan almost daily for anxiety despite no anxiety being documented in behavior logs, and a third resident received PRN olanzapine without documented agitation or prior nonpharmacologic attempts. Staff also confirmed that behavior management plans and individualized interventions were not in place.
PRN psychotropic meds lacked required stop dates for three residents. One resident had a PRN antipsychotic order for agitation that was given multiple times without a stop date, and two residents had PRN lorazepam orders for anxiety/agitation without stop dates. The pharmacist flagged each order as needing compliance with the 14-day limit for PRN psychotropic meds unless the prescriber documented an extension.
The facility failed to support psychotropic use with appropriate diagnoses, timely consent, and documented target behaviors for multiple residents. One resident’s Risperidone consent was incomplete and obtained after the med was started, another resident received ABH cream for restlessness and sundowning that staff and the DON said was part of dementia rather than psychosis, and two other residents had psychotropic orders with behaviors that staff and the regional nurse consultant said did not justify the medications.
A resident’s PRN psychotropic medication lacked a stop date. The resident was observed calm and relaxed on a locked unit, and the RN stated a stop date ensures the resident is re-evaluated by the physician for continued need. The MAR showed no documented behaviors during the review period, yet the lorazepam order remained indefinite.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident received quetiapine without a documented appropriate indication, with no behaviors noted in records or by the DON, and the care plan and MDS did not support antipsychotic use. Another resident received risperidone and quetiapine for dementia-related diagnoses, but records did not identify targeted behaviors, nursing notes showed no behaviors, and GDRs were not attempted for risperidone.
PRN Lorazepam Given Without Consent or Active Order: A cognitively intact resident said he did not want lorazepam and was unaware nursing staff were giving it to him. Records showed the PRN psychotropic was administered multiple times without documented consent, was continued after the order expired, and was not documented on the MAR or in progress notes with the resident’s symptoms or response.
The facility failed to document required IDT and psychotropic assessments before starting and increasing antipsychotic meds for two residents with dementia. One resident’s Rexulti orders changed across diagnoses including dementia, Alzheimer’s disease, bipolar disorder, and major depression, but the chart lacked the required comprehensive evaluation and psychotropic assessment. For another resident receiving Seroquel for dementia with psychosis, the MDS and care plan did not show psychosis behaviors, and staff and the family member reported the resident was generally pleasant with no current behaviors to support the medication use.
Unnecessary Psychotropic Medication Use Without Supporting Diagnosis: A resident with dementia, psychosis, and anxiety received ziprasidone, Depakote, and lorazepam for dementia-related behaviors. Pharmacy requested a supporting dx for ziprasidone per CMS guidelines, but the DON could not locate behavior tracking and confirmed there was no supporting dx for the medication.
A resident with dementia, Parkinson's disease, agitation, and anxiety was prescribed multiple psychotropic meds, including PRN and scheduled injectable Haldol, but the record did not document behaviors or a diagnosis to support the scheduled antipsychotic use. The care plan did not identify target behaviors for Haldol, nursing notes did not justify the order, the first psychotropic observation was delayed, and staff and family reported the resident mainly yelled out and had no other current behaviors. The DON confirmed the resident had duplicative psychotropic meds and that the PRN Haldol order continued beyond the 14-day limit without justification or a new order.
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