Surveyors found that the facility did not ensure medications, including psychotropics, were tied to specific diagnosed conditions and that PRN psychotropic orders were time-limited. One resident with multiple mental health diagnoses was receiving divalproex and quetiapine with indications documented only as “mood stabilizer” and “mood disorder,” which the DON acknowledged were not supported by corresponding diagnoses. Another resident with peripheral vascular disease and extramedullary plasmacytoma was receiving aspirin for “prophylactic measures” and Bactrim DS for “chemotherapy,” despite having no diagnoses matching those indications. A third resident with dementia, anxiety, bipolar disorder, major depressive disorder, and seizure disorder had PRN lorazepam for anxiety and temazepam for insomnia without stop dates or documented rationale for extended PRN use.
Surveyors found that two residents were receiving melatonin, a psychotropic medication, ordered for insomnia without a corresponding insomnia diagnosis documented in their clinical records. Both residents had multiple medical and psychiatric conditions, and physician orders specified melatonin 5 mg for insomnia. In interview, the DON confirmed that the indication for each melatonin order was insomnia, acknowledged that neither resident had an insomnia diagnosis, and stated that medications are required to be documented as treating specific diagnosed conditions, which was not done in these cases.
A resident with an anxiety disorder received PRN hydroxyzine 25 mg for anxious behaviors under a physician order that lacked an end date. MAR review showed repeated administrations of the PRN psychotropic over an extended period. The UM and DON confirmed that the PRN hydroxyzine had been ordered indefinitely and that the provider had not documented a clinical rationale in the medical record for continuing the PRN psychotropic beyond 14 days, contrary to the DON’s stated expectations.
Surveyors found that staff failed to ensure psychotropic medications were medically necessary and linked to documented diagnoses. One resident with multiple medical and psychiatric conditions was receiving citalopram for depression without having a depression diagnosis. Another resident with lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism was receiving fluoxetine and venlafaxine for depression and trazodone for insomnia, despite lacking documented diagnoses of depression or insomnia. The IDON confirmed that these medications were ordered for those indications and that there were no corresponding diagnoses in the clinical records, contrary to the requirement that medications be documented to treat specific diagnosed conditions.
Surveyors found that the facility administered psychotropic medications without ensuring appropriate diagnoses or regulatory-compliant orders. One resident received PRN lorazepam for anxiety and restlessness under an order that was not time-limited to 14 days and did not specify duration, and this resident did not have an anxiety diagnosis. Another resident received scheduled olanzapine for “mood” and trazodone for insomnia, even though “mood” was not an appropriate indication and the resident did not have an insomnia diagnosis. The DON confirmed these discrepancies and acknowledged that psychotropic medications should be linked to proper indications and that PRN psychotropics must be time-limited or have a defined duration.
A resident with dementia, major depressive disorder, anxiety, and restlessness was prescribed quetiapine 50 mg twice daily for agitation and anxiety and received the medication over multiple months. Review of the medical record showed no order for, or documentation of, AIMS assessments despite the ongoing antipsychotic use. During interview, the Regional Clinical Nurse confirmed that the resident lacked an appropriate diagnosis for antipsychotic therapy and that staff did not complete the required AIMS assessments, contrary to facility expectations for psychotropic medication use and monitoring.
Staff failed to ensure that psychotropic and related medications were supported by appropriate diagnoses in the clinical record. One resident with multiple medical conditions, including paraplegia and major depressive disorder, received melatonin for insomnia and tetrabenazine for tardive dyskinesia without documented diagnoses of either condition. Another resident with depression and insomnia was given hydroxyzine for anxiety/agitation without a diagnosis of anxiety. A third resident with respiratory failure, anxiety disorder, dissociative identity disorder, bipolar disorder, and major depressive disorder was prescribed Depakote for dementia with behavioral disturbance despite having no dementia diagnosis. The DON confirmed that these medications were ordered for conditions not documented as diagnoses and acknowledged that medications should be tied to specific, documented conditions.
Surveyors found that a resident receiving an antidepressant for depression was given the medication over several months without any documented monitoring for side effects, despite staff acknowledging that such monitoring should be recorded on the TAR. Additionally, two residents on antipsychotic medications, one with schizophrenia and one with dementia and behavioral disturbance, had repeated pharmacy recommendations for AIMS testing to monitor for tardive dyskinesia and other movement disorders, but there were no physician orders for AIMS and no AIMS assessments documented in their records; the DON confirmed these tests should have been completed and the recommendations followed.
Two residents were prescribed psychotropic medications without evidence of ongoing need or appropriate monitoring. One resident continued to receive antidepressants and other medications despite consistently showing no depressive symptoms, and no gradual dose reduction was attempted or justified. Staff did not monitor for suicidal thoughts or behaviors as required by black box warnings for antidepressant medications, and documentation of such monitoring was absent for both residents. Nursing staff acknowledged a lack of instruction on responding to black box warnings, and the DON confirmed that monitoring and documentation for suicidal ideation were not performed.
A resident with severe dementia and agitation was repeatedly administered Haldol injections without a qualifying diagnosis and without documented attempts at alternative interventions. Staff did not consistently record the reasons for medication use, and interviews revealed that medication was sometimes used as a first-line response to behavioral issues, contrary to facility expectations.
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