Failure to monitor Clozaril labs and involve a guardian in psychotropic treatment decisions. Two residents receiving Clozaril had incomplete or unavailable CBC/ANC monitoring despite provider and psychiatry notes recommending regular lab draws, and a third resident with a guardian had an Abilify GDR without documentation that the guardian was notified or participated in the dose-reduction decision.
A resident with dementia, anxiety, epilepsy, hemiplegia, and repeated falls received frequent PRN lorazepam in both oral and powder forms while also taking scheduled buspirone. Many EMR entries did not identify the specific behaviors prompting use or document non-pharmacological interventions, and the DON and ADON acknowledged the lack of clinical rationale and supporting documentation for the duplicate anxiolytic use.
Lack of Clinical Rationale for Duplicate and Triplicate Antidepressant Therapy: The facility failed to document a clinical rationale for antidepressant duplication in one resident and triplicate antidepressant therapy in another. One resident with Alzheimer’s disease, MDD, insomnia, and anxiety was ordered escitalopram and trazodone, while another resident with MDD, mood disorder, and anxiety was ordered escitalopram, trazodone, and doxepin. Review of nursing, MD, and psych notes found no documentation explaining the use of the multiple antidepressants, and the SWD stated the psychiatric provider was aware of the orders but the rationale was not documented in the new charting system.
Missing Stop Date for PRN Ativan Order: A resident with DM, anxiety, depression, and hospice needs had a PRN Ativan order with a blank end date, resulting in no 14-day stop date being documented. The chart showed the PRN Ativan was reinstated as ordered, but there were no further notes on the order.
The facility failed to document appropriate indications and behavior monitoring for psychotropic medication use for multiple residents. Records showed antidepressant, anti-anxiety, and antipsychotic medications ordered for residents with diagnoses such as dementia, depression, anxiety, stroke, and psychotic disturbance, but nursing notes and Behavior Management Team documentation often lacked resident behaviors, assessment, or justification for use. Staff interviews confirmed missing documentation and inconsistent understanding of the Behavioral Management process, and one resident’s consent reasons did not match the order indications.
A resident with severe cognitive impairment, dysphagia, and NPO status exhibited frequent behaviors including yelling out, repeatedly requesting water, drinking from inappropriate sources, pulling out a G‑tube, and removing O2. The care plan identified behavioral problems related to unsafe drinking but contained only generic statements and no specific, individualized interventions. Nursing staff and the SSD reported daily behaviors and limited interventions beyond checking on the resident, while the family stated they were not asked for input on non‑pharmacologic strategies and had expressed a desire to avoid sedation. Despite a facility policy requiring thorough assessment and trial of person‑centered non‑drug approaches before psychotropic use, the resident was maintained on Seroquel for behavior and later started on clonazepam, which was then increased for restlessness, anxiety, and behavioral issues without documented comprehensive assessment or clear evidence that individualized non‑pharmacologic interventions had been implemented and evaluated first.
The facility failed to prevent unnecessary psychotropic use for two residents. One resident with dementia and anxiety remained on risperidone for an extended period despite intact cognition, no documented behaviors, and repeated pharmacy reviews stating that anxiety was not an acceptable antipsychotic indication and that the diagnosis needed clarification or the drug should be tapered. The record also showed delayed or absent GDRs, unclear justification for the antipsychotic, and staff acknowledgment that anxiety was not an appropriate diagnosis for risperidone.
Unclear indication and rationale for duplicate antipsychotic therapy. A resident with dementia, anxiety, adjustment disorder, psychotic disorder with delusions, and insomnia was prescribed two antipsychotics: paliperidone ER daily and quetiapine BID. Review of MH provider notes found no documented clinical rationale for the dual therapy, and the SW stated the chart did not explicitly address why both medications were being used.
A resident with dementia with psychotic disturbance and hospice services was started on PRN Ativan for anxiety/restlessness after hospice input, with non-pharmacologic interventions documented before administration. The PRN order was later extended to 90 days, but the record lacked documentation supporting use beyond the initial 14-day period; staff later gave additional doses for wandering/restlessness, and an NP reported re-evaluations of the medication.
Psychotropic medications were ordered for four residents without a documented, specific diagnosis or clinical indication in the chart. The EMR showed orders for antidepressants, an antipsychotic, and Xanax, but the diagnosis fields were blank or the record otherwise lacked support for why the meds were being used. The NP said prescriptions were written with an active dx, while the DON said the dx was not entered into the EMR.
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