A resident with Alzheimer's disease was ordered Olanzapine as PRN for nighttime agitation and increased fall risk, but the MAR showed it was given nightly instead. The resident was coded as cognitively intact, and staff interviews found no documented agitation, behaviors, or falls after admission, while the NP and Medical Director acknowledged the order should have reflected PRN use.
A resident with dementia, severe behavioral disturbance, and agitation was receiving scheduled oral haloperidol for behaviors, but the facility failed to complete ongoing AIMS assessments after the last one documented several months earlier. The resident’s quarterly MDS reflected cognitive impairment, behavioral symptoms, and antipsychotic use, yet no corresponding quarterly AIMS was found in the EMR. The unit manager and DON reported that AIMS assessments were expected at admission, readmission, with new prescriptions, and quarterly, but acknowledged that required assessments were missed following a change in facility ownership. The pharmacy consultant and Medical Director both indicated AIMS should be performed at least every 6 months for residents on antipsychotics, confirming that the resident’s monitoring was not completed as expected.
A resident with anxiety disorder, who was cognitively intact and receiving antianxiety medications, had a PRN Clonazepam order entered into the EMR without the required 14‑day stop date. The PRN psychotropic order remained active and was administered at least once, while multiple staff, including the nurse who entered the order, the unit manager, the DON, and the Medical Director, were unable to clearly identify how the order was initiated or why it lacked a stop date. Although new medication orders were reportedly reviewed in daily morning meetings, this PRN Clonazepam order without a stop date was not identified or corrected through that process.
A resident with anxiety disorder, colon cancer, and severe cognitive impairment, who was on hospice care, had a PRN Lorazepam order for anxiety that remained active for several months without a documented stop date or specified duration. The medication, a psychotropic and controlled substance, was administered two to three times weekly via PEG tube, while the EMR and MARs showed no 14-day limit or documented rationale for extending the PRN order. Nursing staff and a hospice nurse reported the resident experienced agitation and anxiety during care, and facility leadership and physicians acknowledged that PRN psychotropic medications should include a stop date, be reviewed within regulatory timeframes, and have a clear rationale and duration, which did not occur in this case.
Two residents were administered antipsychotic and antidepressant medications without appropriate mental health diagnoses, and a PRN antipsychotic was ordered for longer than regulations allow. Staff, including the DON and Consultant Pharmacist, did not verify medication orders for compliance, relying instead on pharmacy review and assuming hospice orders were exempt from certain requirements.
The facility failed to complete required Abnormal Involuntary Movement Scale (AIMS) assessments for multiple residents receiving antipsychotic medications. One resident on nightly olanzapine had only a single AIMS documented despite a care plan intervention calling for AIMS testing per protocol. Another resident on daily olanzapine, who was severely cognitively impaired and received antipsychotics per the MDS, had no AIMS assessments and no care plan intervention addressing AIMS. A third resident on scheduled quetiapine with documented behavioral symptoms and a prior GDR also had no AIMS assessments and no care plan focus on antipsychotic use. Interviews with the DON, consultant pharmacist, medical director, physician, and administrator showed they were unaware of AIMS frequency requirements, believed AIMS might be captured in the MDS or EMR, and lacked a tracking process, leading to missed and overdue AIMS assessments.
Two residents receiving antipsychotic medications did not receive ongoing Abnormal Involuntary Movement Scale (AIMS) assessments as required by protocol. Although care plans identified the need for regular AIMS testing due to the risk of complications from psychotropic medications, only a single assessment was documented for each resident. Staff interviews revealed that the EMR system may not have been set to trigger reminders for these assessments, and some staff were unaware of the requirement for ongoing AIMS evaluations.
A resident with anxiety disorder and severely impaired cognition had an active PRN lorazepam order without the required 14-day stop date, despite staff awareness of CMS guidelines. The order remained in effect for over a month, even after the resident was started on scheduled lorazepam, due to an oversight by the Medical Director and Consultant Pharmacist.
A resident with an anxiety disorder was prescribed lorazepam, including a PRN order, without a required stop date for reassessment. The omission was identified during a consultant pharmacist's review, but the missing stop date was not initially flagged or corrected during routine clinical meetings, resulting in a deficiency related to the management of psychotropic medications.
PRN antipsychotic order lacked stop date and diagnosis. A resident with Parkinsonism, DM2, insomnia, BPH, and HF had a PRN quetiapine order for agitation that started without an end date, and the record did not show a supporting psychiatric or mood disorder diagnosis. Nursing notes and observations showed the resident was often sleepy, restless, or agitated, and staff documented mixed effectiveness of the medication. An RN stated the PRN antipsychotic was ordered after the resident reportedly became physically aggressive, and she knew PRN antipsychotics required a stop date and diagnosis.
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