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.
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.
Unjustified Increase in Antipsychotic Medication: A resident with anxiety disorder, delusional disorders, and vascular dementia received an increased Seroquel dose despite no recent documented behaviors, hallucinations, or delusions in the chart. Psychiatry noted the resident had been stable, but hospice and nursing notes later referenced yelling out and anxiety at lunch, leading to an added afternoon Seroquel dose on top of the existing BID order. Staff interviews confirmed behavior documentation was limited.
The facility failed to document a clinical rationale for duplicate antidepressant therapy for a resident who was receiving Amitriptyline HCl and Venlafaxine HCl ER, with no depression diagnosis listed in the chart. The facility also failed to ensure appropriate monitoring for another resident receiving Quetiapine, as the record showed only CBC and CMP results and no documented Hgb A1c monitoring despite the DON’s report that it should be checked within 6 months of starting Seroquel and every 6 months thereafter.
Two residents had open-ended PRN psychotropic orders without stop dates. One resident with dementia and other medical diagnoses had PRN Prochlorperazine for nausea/vomiting, with no care plan mention or side-effect monitoring documented, despite a pharmacy review recommending discontinuation or a specific duration. Another resident with vascular dementia, psychotic disturbance, mood disturbance, and anxiety had PRN Ativan for anxiety and agitation; staff reported it was effective for severe behaviors, but the order remained open-ended even after pharmacy review noted the issue and hospice was referenced on the form.
A resident with Bipolar II Disorder, Schizoaffective Disorder, and Schizophrenia was receiving clozapine, but the facility did not adequately monitor CBC/ANC results. The chart showed a CBC q60 days order and later references to monthly CBC monitoring, yet the order summary did not reflect monthly CBC with differential labs, and the last CBC in the record was months earlier. Psychiatry notes continued to recommend monthly CBC monitoring, while the DON stated staff were unaware of the lab testing requirements for Clozaril and the pharmacy had not recently requested CBC or ANC results.
The facility failed to justify continued PRN psychotropic use beyond the 14-day limit for a resident with a history of falls and muscle weakness. The resident had moderate cognitive impairment on BIMS and an active PRN Ativan order for anxiety/agitation that remained in place past 14 days; an RN acknowledged the order should have been discontinued and reevaluated.
A resident with mental health diagnoses was prescribed PRN hydroxyzine for anxiety without a 14-day stop date, and no provider rationale was documented to justify use beyond this period. The DON confirmed that the required stop dates were not in place for the medication orders.
A resident with severe cognitive impairment and a right lower leg fracture was prescribed Seroquel, but the chart showed no physician order and no documented orthostatic BP monitoring despite the care plan listing it as an intervention. The DON confirmed that residents on antipsychotic meds require monthly orthostatic BP checks and that the EMR lacked this monitoring.
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