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.
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.
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.
A resident who was cognitively intact was given quetiapine for prophylaxis without a documented supporting diagnosis. The MAR showed the antipsychotic was administered for several days, but the hospital H&P, rehab prescriptions, prior med list, and psychotropic consent did not include it. The DON could not find a reason for the Seroquel order, and the APRN later discontinued it after finding no appropriate indication.
Unnecessary psychotropic medication use and lack of nonpharmacologic interventions were identified for three residents. One resident with dementia, anxiety, and depression received clonazepam, hydroxyzine, fluoxetine, loxapine, and memantine, but the care plan lacked resident-specific interventions despite repeated yelling out and anxiety. A second resident with neurocognitive disorder, Alzheimer’s disease, depression, and anxiety received scheduled and PRN lorazepam plus risperidone, while documentation of behaviors was inconsistent and limited. A third resident with dementia and psychotic disturbance received olanzapine and sertraline even though nursing notes and the care plan did not document behaviors, and the resident was observed pleasant and engaged with others.
A resident with schizophrenia and other comorbidities, who was cognitively intact and reported signing their own consents, had two PRN haloperidol orders (IM and oral) written with indefinite end dates and left in place for an extended period, contrary to federal requirements and facility policy that PRN psychotropic and antipsychotic medications be limited to 14 days with documented rationale and duration for any extension. The resident reported that staff were giving medications at incorrect times, sometimes late or not at all, and that staff did not listen to concerns about medication dosing. The ADON, DON, and NP acknowledged that PRN psychotropics should be time-limited and reassessed, and facility policies specified 14‑day limits, required physician evaluation and documentation for extensions, and required informed consent and clear indication for use, but these requirements were not implemented for this resident’s PRN haloperidol orders.
A resident with dementia, anxiety disorder, depression, insomnia, restlessness, agitation, and a history of falls had a PRN Ativan order for agitation/anxiety/restlessness that did not include a stop date. The DON stated PRN Ativan should have a 14-day stop date, and the facility’s psychotropic medication policy required licensed nurses to enter all PRN orders with a 14-day stop date.
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