Failure to document GDR or rationale for psychotropic use: A resident with dementia, TBI, anxiety, and depression was receiving escitalopram and quetiapine, with no behaviors noted during the assessment period. Pharmacy recommended review of continued use and a clinical rationale if doses were maintained, but the record did not show a GDR attempt or documented rationale for not completing one; the DON stated that documenting the resident as stable was not an appropriate rationale.
PRN antipsychotic order lacked required stop date. A resident with severe cognitive impairment, dementia, anxiety, depression, wandering, and behavioral symptoms received PRN Haloperidol repeatedly, but the order was entered as indefinite even though it was written for 14 days. Staff said the medication was used when redirection failed and behaviors disturbed others, and the LPN, RN, and DON confirmed PRN psychotropic meds should have an end date and be re-evaluated after 14 days.
PRN psychotropic medication was left active beyond the required 14-day limit for a resident with moderately impaired cognition, depression, and chronic pain. The resident had a PRN lorazepam order for anxiety/restlessness that lacked a stop date, and the EHR did not include a provider rationale for continued use beyond 14 days. The RNCM and DON reviewed the record and confirmed the order should have had a 14-day stop date unless hospice criteria applied.
A resident with intact cognition and diagnoses including respiratory failure, COPD, and tracheostomy status received PRN lorazepam and PRN quetiapine with stop dates that allowed both psychotropic orders to remain active beyond the 14-day limit, without documented practitioner rationale or evaluation to support continued use. The facility also did not order or complete orthostatic BP monitoring for the resident’s antipsychotic use, and the RNCM and DON confirmed the 14-day requirements and the need for orthostatic monitoring.
A resident with comfort-care lorazepam PRN had a pharmacist recommendation for review and rationale that was not acted on within the expected timeframe, and another resident receiving Celexa had no documented target symptoms or behaviors on the care plan to monitor antidepressant effectiveness. The RN and DON confirmed the missing review and lack of care plan identification for psychoactive medication monitoring.
Failure to Complete Ordered Orthostatic BP Monitoring: A resident with moderately impaired cognition, CHF, HTN, anxiety, and depression received Olanzapine and other psychotropic medications, and had an active order for monthly orthostatic BP checks. The EHR showed no evidence the ordered monitoring was completed for several months, and the RN case manager confirmed the task had not been generated and the monitoring had not been done; the DON stated the ordered monitoring should have been completed.
Failure to Monitor Psychotropic Medication Use: A resident receiving duloxetine for depression did not have identified target behaviors or side effect monitoring documented in the care plan, TAR, or medical record. An LPN, the unit nurse manager, the DON, and the regional nurse consultant all confirmed the monitoring was not in place for the resident’s psychotropic medication use.
A resident with significant cognitive impairment, dementia with agitation, anxiety disorder, and hospice care for Alzheimer’s dementia received PRN olanzapine orders that were repeatedly renewed without documentation of a new order every 14 days or a required provider evaluation. The EMR lacked evidence of a face-to-face provider visit justifying continued use, while staff stated hospice handled the medication renewals and the DON confirmed PRN antipsychotic orders were only good for 14 days.
A resident with dementia, depression, diabetes, and CHF was receiving hospice care and had an open-ended PRN order for Haldol for agitation/restlessness. The record showed no documented face-to-face provider evaluation or justification for continued use after the consultant pharmacist twice recommended discontinuation under the 14-day PRN antipsychotic limit. Staff also noted the medication made the resident sleepy, and the MAR showed it was administered during the review period.
The facility failed to manage psychotropic medications appropriately for two residents. One resident receiving an antipsychotic had missing monthly orthostatic BP monitoring documentation for multiple months, and another resident’s PRN lorazepam order lacked a stop date, specific duration, or documented prescriber rationale for use beyond 14 days. Staff and the DON confirmed the monitoring and PRN order requirements were not met.
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