A resident with anxiety, restlessness, agitation, and moderately impaired cognition received PRN lorazepam for anxiety, but the order had no stop date and the EHR lacked a documented duration with physician rationale for continued use. The psychotropic care plan did not address the PRN lorazepam, and an RN verified the facility had not obtained the required 14-day stop date or documentation for ongoing use.
A facility failed to document appropriate indication and physician rationale for continued antipsychotic use for two residents. One resident with dementia and Parkinson’s disease received Zyprexa for agitation, and another resident with psychotic disorder and severe cognitive impairment received risperidone for vascular dementia; in both cases, the record lacked evidence of unsuccessful nonpharmacological interventions and risk-versus-benefit documentation. An admin nurse verified the medications were being given and stated the facility would contact the physician for appropriate documentation.
A resident with dementia, agitation, and severe cognitive impairment received routine antipsychotic therapy and an antidepressant for behavior-related concerns without documented indication or a physician rationale that included risks versus benefits. The chart showed a GDR attempt, pharmacist recommendations to reevaluate the psychotropics, and ongoing behaviors such as wandering, entering other residents’ rooms, and being difficult to redirect, while an admin nurse confirmed the lack of documentation for the medication indication.
PRN Benadryl Lacked Required Stop Date: A resident with dementia, insomnia, anxiety, and severely impaired cognition had a PRN Benadryl order for insomnia that did not include a stop date or specified duration. The LN and an Administrative Nurse stated the order should have had an automatic 14-day stop date, and the facility’s psychotropic med policy required psychotropics to be clinically indicated and not used as a chemical restraint.
Psychotropic Medication Monitoring and PRN Stop-Date Deficiencies: A resident with anxiety received a PRN anxiolytic order without the required 14-day stop date or documented duration/rationale, and another resident with depression and insomnia received multiple antidepressants without documented monitoring for target behaviors or side effects. Staff stated PRN psychotropic orders required a stop date and psychotropic meds were monitored each shift, but the EMR and care plan documentation did not reflect those requirements.
A resident with epilepsy, anxiety, HTN, and moderately impaired cognition received PRN Ativan under an order that lacked a stop date. The EMR did not show a specified duration or physician rationale for the ongoing PRN use, and an RN verified the medication had been given under that order.
A resident with dementia, major depressive disorder, stroke history, and other chronic conditions received routine Seroquel for behavior management without documentation of an appropriate indication, physician rationale, or attempted nonpharmacological interventions. The record showed intermittent verbal aggression, yelling, and inappropriate comments, but the EMR lacked evidence of a documented risks-versus-benefits review or a GDR attempt, and staff interviews showed uncertainty about the antipsychotic indication and behavior documentation.
A resident with anxiety and HTN had PRN lorazepam and PRN Xanax orders that lacked stop dates and did not include a documented physician rationale or specified duration for extended use. The care plan did not reflect the PRN use of either medication, and the RN verified the orders were active without the required documentation.
PRN Ativan Order Lacked Required Stop Date or Rationale: A resident with anxiety, dementia, pain, and a terminal diagnosis had a PRN Ativan order for anxiety that lacked a stop date. The record also lacked a specified duration and physician rationale for continuing the psychotropic medication beyond 14 days, and staff stated the resident was on comfort care and receiving PRN Ativan without a stop date being considered.
A facility failed to document an appropriate indication and physician rationale for continued antipsychotic use for two residents. One resident with dementia and behavioral disturbance and another resident with Alzheimer’s disease and hallucinations were receiving Seroquel, but their records lacked documentation of unsuccessful nonpharmacological interventions and a risk-versus-benefit rationale for the medication. Observations showed an LN administering the residents’ medications, and the RN later verified both residents were receiving Seroquel.
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