Two residents received antipsychotic meds without documented appropriate diagnoses, and one resident also had no documented GDR attempt. One resident was on Zyprexa for dementia-related behaviors despite records showing severe cognitive impairment and no hallucinations, delusions, behaviors, or rejection of care, while another resident was on quetiapine for anxiety and sleep disorder with no documentation supporting the diagnosis or a GDR attempt. The DON and Admin stated they would expect correct diagnoses and attempted GDRs when appropriate.
The facility failed to have an appropriate diagnosis for one resident's antipsychotic order and failed to limit another resident's PRN antipsychotic order to 14 days. One resident received quetiapine for depression despite diagnoses including Parkinson's disease with dyskinesia, and another resident had haloperidol PRN for hallucinations with no stop date. The DON, Administrator, and MD stated psychotropic meds should have an appropriate diagnosis and PRN antipsychotics should have a 14-day stop date.
A resident with dementia and a history of stroke was admitted without psychotropic medications and initially assessed as alert and pleasant, yet staff quickly obtained and administered IM haloperidol for attempts to ambulate without assistance, followed by multiple PRN and scheduled orders for risperidone, lorazepam, Zoloft, and Seroquel for behaviors such as anxiety, yelling, roaming, and standing up from a wheelchair. The facility did not complete a comprehensive assessment or develop a care plan addressing antipsychotic use, and nursing documentation frequently lacked detailed descriptions of behaviors, nonpharmacological interventions, or behavior monitoring at the time medications were given. Interviews with an RN, DON, NP, physician, and the Administrator confirmed that the indications and dosing for antipsychotics, including high-dose risperidone and IM haloperidol, were not appropriate for the behaviors described and that nonpharmacological approaches should have been attempted first, contrary to facility policy requiring residents to be free from chemical restraints and mandating thorough, interdisciplinary care planning.
A resident with anxiety and depression had a PRN lorazepam order without the required 14-day stop date, and another resident receiving aripiprazole had no documented diagnosis supporting the antipsychotic use. The DON and Administrator acknowledged that PRN psychotropics should have a 14-day stop date and that all medications should have an appropriate diagnosis.
A resident with dementia and agitation was receiving multiple psychotropic medications, including scheduled antianxiety, antidepressant, antipsychotic, and anticonvulsant drugs. Staff documented repeated episodes of pacing, wandering, aggression, sexual inappropriateness, and restlessness, but progress notes did not show detailed behaviors, triggers, or non-pharmacological interventions before PRN lorazepam was given. The care plans were general and did not include comprehensive target behaviors or individualized interventions, and the PRN lorazepam order lacked a stop date.
The facility failed to limit PRN psychotropic medication orders to 14 days for one resident and failed to ensure an appropriate diagnosis supported Seroquel use for another resident. One resident with dementia with psychotic disturbance remained on Seroquel without documentation addressing the black box warning, diagnosis, or behaviors, while another resident on hospice had a PRN lorazepam order for anxiety/terminal restlessness without a 14-day stop date. The DON acknowledged PRN psychotropics should have a 14-day stop date, and the Administrator stated policy should be followed.
Failure to attempt GDR for psychotropic meds: two residents remained on antipsychotic therapy without required GDR documentation. One resident with bipolar disorder, dementia, PTSD, anxiety, Parkinson's disease, and polyneuropathy had Abilify 15 mg daily with pharmacist requests to reduce the dose, but no physician response or proof the requests were sent. Another resident with schizophrenia, MDD, PTSD, Parkinson's disease, restless leg syndrome, and cerebral infarction had Risperdal 1 mg daily with no documentation of a GDR request, GDR attempt, or clinical contraindication.
Psychotropic Medications Used Without Adequate Assessment or Behavioral Documentation: The facility ordered and increased antipsychotic and other psychotropic meds for residents with dementia without documenting a comprehensive assessment, approved indication, or consistent non-pharmacological interventions. One resident had repeated aggression, wandering, and refusal of care, yet the record lacked rationale for Seroquel and later Haldol, then risperidone caused marked lethargy. Another resident had wandering and exit-seeking with repeated redirection before receiving multiple psychotropics, and a third resident’s Seroquel was increased despite limited documented behaviors and later calm observations. The record also lacked a GDR or contraindication for one resident’s antidepressant.
Staff failed to document the clinical rationale for administering PRN antipsychotic and antianxiety medications to a resident with multiple psychiatric diagnoses. Despite facility policy requiring assessment and documentation of behaviors or symptoms justifying PRN use, staff administered these medications without recording the necessary behavioral evidence in the progress notes, as confirmed by MAR reviews and staff interviews.
A resident on hospice with generalized anxiety had a PRN haloperidol order for anxiety with no stop date, and the order remained active over multiple months with doses documented on the MAR. An LPN said the resident usually refused the medication and it should be discontinued, while the DON and ADON said they had not been tracking psychotropic use and did not expect floor nursing staff to monitor stop dates. The ADON acknowledged PRN psychotropics are expected to have a 14-day stop date and reassessment.
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