Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Unnecessary psychotropic medication management failures were identified for multiple residents. A resident had a PRN lorazepam order without the required stop date or documented GDR support, another resident’s psychoactive review omitted scheduled and PRN antipsychotics, and lab monitoring for antipsychotic use was not documented for another resident. A fourth resident had PRN lorazepam for dental procedures without an end date, and staff interviews confirmed missing documentation for PRN duration, GDRs, and monitoring.
Failure to attempt GDRs for 2 residents receiving psychotropic meds. One resident with severely impaired cognition, psychosis, depression, restlessness, and agitation remained on Zoloft and Ativan with repeated provider continuation requests, but no documented GDR attempt or psychotropic review recommendation. Another resident with moderate cognitive impairment, dementia, depression, restlessness, and agitation received sertraline and Seroquel, yet records showed no GDR attempt within the first 6 months of admission and staff/pharmacy did not identify the need for one.
Lack of Psychotropic Medication Monitoring and Resident-Specific Target Behaviors: The facility failed to document resident-specific target behaviors and side effect monitoring for psychotropic medications for three residents. One resident with schizophrenia and anxiety had multiple psychotropic orders, another resident with recurrent major depressive disorder had venlafaxine ordered, and a third resident with generalized anxiety disorder had mirtazapine ordered, but the EMR, MAR/TAR, and care plans lacked the required resident-specific behavior targets and side effect monitoring. Staff stated that behavior documentation was generic and that target behaviors should have been included in the care plan and MAR/TAR.
A resident receiving olanzapine had ordered orthostatic BP monitoring in the lying, sitting, and standing positions, but the measurements were not completed for several months. The resident had no cognitive impairment or psychosis noted on the MDS, and pharmacy reviews did not address the missed monitoring. The DON stated monthly orthostatic BP checks were expected, while the pharmacist said she reviewed the order but did not routinely verify completion.
Failure to Monitor Psychotropic Medication Side Effects: A resident with major depressive disorder was receiving duloxetine and trazodone, but the care plan, MAR/TAR, order summary, and progress notes lacked documentation of side effect monitoring or identification of what side effects to monitor. Staff interviews showed uncertainty about whether psychotropic side effect monitoring was being done, and the RN later verified the care plan did not include the required monitoring.
A resident with Parkinson's disease and a history of hallucinations was restarted on Seroquel 25 mg daily, but the record did not show new behavioral symptoms or documented behavior monitoring to justify the antipsychotic. The chart linked the medication to increased tremors, although the PCP later stated tremors were not an indication for Seroquel and that he would not prescribe it for Parkinson's symptoms. Staff interviews confirmed the lack of documented target behaviors, and the resident was observed appropriately dressed, groomed, and answering questions clearly.
Missing Instructions for Multiple PRN Psychotropic Medications: A resident with dementia, Alzheimer’s disease, anxiety, depression, and a psychotic disorder had PRN lorazepam and PRN Depakote ordered for agitation, but the care plan and order summary did not include instructions on which medication to give first or how to choose between them. An LPN stated he was unsure which PRN to use first and would just pick one, and an RN confirmed the orders lacked administration guidance.
A resident receiving Risperdal had no documented orthostatic BP monitoring in the orders, care plan, vital signs record, or progress notes. The resident’s psychotropic care plan lacked orthostatic BP guidelines, and an LPN, RN, and RCS confirmed the monitoring task and order were not completed despite the facility’s protocol for antipsychotic side effect monitoring.
Failure to document PRN AP use and provider review: A resident with intact cognition and diagnoses including dysthymic disorder, anxiety, adjustment insomnia, and delusional disorder received repeated PRN olanzapine orders and administrations for agitation or anxiety, but the EMR lacked correlating behavior documentation and evidence of a face-to-face provider visit before the PRN AP was renewed. Staff and the pharmacy consultant stated the PRN AP should have been limited to 14 days unless the provider evaluated the resident and documented the need for continued use.
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